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THE  MEDICAL  REPORT  OF  THE 
RICE  EXPEDITION  TO  BRAZIL 


BY 

W.  T.  COUNCILMAN,  M.D. 

AND 

R.  A.  LAMBERT,  M.D. 

FROM  THE  SCHOOL  OF  TROPICAL  MEDICINE 
HARVARD  UNIVERSITY 


CAMBRIDGE 
HARVARD  UNIVERSITY  PRESS 

LONDON:    HUMPHREY  MILFORD 

Oxford  University  Press 

1918 


fittt  9i  the  i-'rcSiUoDi 

AUG  7-  1918 

COPYRIGHT,  1918 
HARVARD  UNIVERSITY  PRESS 


TO 
MRS.  A.  HAMILTON  RICE 

AS  AN  APPRECIATION  OF  HER  ENDURANCE, 

PATIENCE,  FORTITUDE,  AND  CHEERFULNESS 

THIS   WORK    IS    RESPECTFULLY    DEDICATED 

BY  THE  AUTHORS 


INTRODUCTION 

The  expedition,  primarily  undertaken  for  geographical 
research,  was  organized  by  Doctor  A.  Hamilton  Rice, 
and  left  New  York  on  the  steam  yacht  Alberta,  Novem- 
ber 16,  1916.  The  members  of  the  expedition  were 
Doctor  and  Mrs.  A.  H.  Rice,  Mr.  Howe,  geologist, 
Mr.  Swanson,  wireless  operator,  Mr.  Cousens,  engineer, 
Mr.  Church,  cartographer,  and  the  writers.  Stops  were 
made  on  the  way  to  and  from  Brazil  at  Barbados  and  at 
Porto  Rico.  From  Barbados  we  proceeded  on  the  yacht 
to  Para,  to  Manaos,  and  to  Iquitos  in  Peru,  returning 
from  there  to  Manaos.  At  Manaos  a  river  steamer  was 
taken  to  San  Isabel  on  the  Rio  Negro,  and  from  there 
we  proceeded  to  San  Gabriel  on  a  launch  which  was 
constructed  in  New  York  for  this  purpose,  and  sent  to 
Manaos  on  a  commercial  steamer. 

The  main  purpose  of  the  expedition  was  the  study  of 
the  physical  geography  of  the  Casiquiare  Canal  (a 
natural  waterway  between  the  Rio  Negro  and  the  Ori- 
noco River),  the  branches  of  this,  and  the  region.  This 
particular  region  has  enjoyed  an  unenviable  reputation 
from  the  great  numbers,  the  variety,  and  the  rapacity 
of  the  insects,  and  from  the  severe  character  of  the 
endemic  diseases.  It  is  also  a  region  which  is  rarely 
visited  save  by  the  rubber  traders  and  about  which 
little  is  known.  Owing  to  the  unprecedented  low  water 
in  the  Rio  Negro  it  was  not  possible  to  go  further  up 
than  to  San  Gabriel,  where  we  waited  for  three  weeks 
in  daily  expectation  of  a  rise  in  the  river.     The  river. 


vi  INTRODUCTION 

however,  continued  to  fall,  and  reports  from  higher  up 
were  that  the  canal  was  not  passable  even  for  a  large 
canoe.  From  San  Gabriel  the  return  to  Manaos  was 
made  on  the  launch,  one  of  the  party  only  (W.  T.  C.) 
coming  down  the  river  from  San  Isabel  on  a  steamer. 
In  the  ascent  of  the  Rio  Negro  the  south  bank,  the  usual 
route,  was  followed,  and  the  descent  to  Manaos,  which 
was  made  in  the  launch,  was  to  a  considerable  extent 
along  the  north  bank,  which  is  little  known.  Both  going 
and  coming  stops  were  made  at  the  small  towns  and 
villages,  and  at  many  of  the  rubber  estates,  and  the 
inhabitants  were  examined.  The  prolonged  stay  at  San 
Gabriel  gave  a  good  opportunity  for  the  study  of  the 
conditions  of  the  region.  From  Manaos  one  of  the 
party  (W.  T.  C.)  made  a  trip  on  a  river  steamer  through 
the  series  of  rivers,  lakes,  and  streams  on  the  south  of 
the  Amazon  between  Manaos  and  the  Madeira  river. 
In  passing  up  the  Amazon  to  Iquitos  a  number  of  stops 
were  made  at  the  small  towns  along  its  banks.  In  Para, 
Manaos,  and  Iquitos  the  hospitals  were  visited  and  the 
cases  in  the  wards  were  studied.  All  of  the  physicians 
encountered  were  most  kind,  and  all  medical  facilities 
were  freely  placed  at  our  disposal.  This  was  in  accord 
with  the  hospitality  shown  us  everywhere. 


MEDICAL  REPORT  OF  THE  RICE 
EXPEDITION  TO  BRAZIL 


MEDICAL  REPORT  OF  THE  RICE 
EXPEDITION  TO  BRAZIL 

The  Amazon  Valley 

It  is  necessary  before  a  consideration  of  the  diseases 
of  this  region  to  give  some  account  of  its  physical  char- 
acteristics, for  the  two  are  closely  interlinked.  The  land 
of  the  Amazons,  including  the  great  valley  and  the  lower 
watershed,  is  in  several  respects  the  most  remarkable 
and  interesting  region  on  earth.  It  is  the  largest  area 
on  earth  which  can  be  treated  as  a  unit  and  in  which 
practically  the  same  conditions  prevail.  There  are 
various  estimates  of  its  extent,  ranging  from  1,500,000 
to  2,722,000  square  miles,  the  difference  depending 
upon  what  are  regarded  as  the  limits  of  the  region.  The 
region  extends  in  the  west  to  the  Andes,  to  the  high 
table-lands  of  the  Matto  Grosso  in  the  south,  to  the 
high  lands  and  the  coastal  range  of  mountains  on  the 
east,  broken  only  by  a  few  hundred  miles  at  the  mouth 
of  the  river,  and  to  the  mountains  of  Venezuela  and 
Guiana  on  the  north.  The  valley  itself  is  almost  as  flat 
as  the  sea.  There  has  been  much  difficulty  in  ascertain- 
ing altitude  owing  to  the  influence  of  atmospheric  con- 
ditions on  the  barometer.  The  very  careful  estimates  of 
Rice  made  on  this  expedition  give  83  feet  at  Manaos, 
and  315  feet  at  Iquitos,  151  at  San  Isabel  and  225  at  San 
Gabriel.  The  trade  winds  sweep  across  the  valley  from 
east  to  west  carrying,  in  great  purple  and  white  cumulus 
clouds,  masses  of  water  vapor,  which  partly  is  preci- 
pitated over  the  valley  in  passing,  but  the  height  of 

3 


4  THE  RICE  EXPEDITION  TO  BRAZIL 

discharge  is  reached  on  the  slopes  of  the  Andes,  where 
the  clouds  meet  the  cold  air  of  the  mountains.^  A  glance 
at  a  map  shows  great  numbers  of  rivers  coming  from  the 
north  and  south,  which  flow  into  the  Amazon,  and 
these  become  more  numerous  in  the  west  as  the  Andes 
are  approached.     The  volume  of  water  discharged  is 

^  "  The  northeast  trade  winds  commence  to  blow  about  the  Tropic  of 
Cancer,  and  coming  from  the  quarter  thej^  do,  they  blow  obliquelj^  across 
the  Atlantic.  Thej'  evaporate  from  the  sea  as  they  go;  and,  impinging  at 
right  angles  upon  the  South  American  shore-line  that  extends  from  Cape 
St.  Roque  to  Cabo  La  Vela,  they  carry  into  the  interior  the  vapor  that 
forms  the  clouds  that  give  the  rain  which  supplies  with  water  the  Mag- 
dalena,  the  Orinoco,  and  the  northern  tributaries  of  the  Amazon. 

The  volume  of  water  discharged  by  these  rivers  into  the  sea  is  expres- 
sive of  the  quantity  which  those  northeast  trade  winds  take  up  from  the 
sea,  carry  in  the  clouds,  and  precipitate  upon  the  water-shed  that  is  drained 
by  these  streams.  They  are  but  pipes  and  gutters  which  Nature  has 
placed  under  the  eaves  of  the  great  water-shed  that  has  the  Andes  for  a 
ridge-pole,  the  Caribbean  sea  and  North  Atlantic  for  a  cistern. 

The  trade-wind  region  of  the  North  Atlantic  affords  the  water-surface 
where  the  evaporation  is  carried  on  that  supplies  with  rains,  dews,  and 
moisture.  New  Granada,  Venezuela,  the  three  Guianas,  and  the  Atlantic 
slopes  of  Ecuador. 

On  the  other  hand,  the  southeast  trade  winds  commence  to  blow  about 
the  parallel  of  30°  or  35°  south.  They,  too,  come  obliquely  across  the 
Atlantic,  and  strike  perpendicularly  upon  the  South  American  coast-line 
which  extends  from  Cape  St.  Roque  towards  Cape  Horn.  They  pass  into 
the  interior  with  their  whole  load  of  moisture,  every  drop  of  which  is 
wrung  from  them  before  they  cross  the  Andes.  The  quantity  of  moisture 
which  is  taken  up  from  the  sea  and  rained  down  upon  this  wonderfully 
fruitful  country  may  be  seen  in  what  the  La  Plata  and  the  Amazon  dis- 
charge back  into  the  ocean. 

Now,  there  is  no  tropical  country  in  the  world  which  has  to  windward, 
and  so  exactly  to  windward  of  it,  such  an  extent  of  ocean  in  the  trade-wind 
region.  Consequently  there  is  no  inter-tropical  country  in  the  world  that 
is  so  finely  watered  as  is  this  great  Amazon  country  of  South  America. 

Along  the  Atlantic  coast  of  the  LTnited  States,  along  the  coast  of  China, 
and  the  east  coast  of  New  Holland,  the  land  trends  along  with  the  direction 
of  the  trade  winds  of  those  regions.  These  winds,  with  their  moisture, 
travel  along  parallel  with  the  land.  They  do  not  blow  perpendicularly 
upon  it,  nor  push  their  vapors  right  across  it  into  the  interior,  as  they  do  in 
South  America.  The  consequence  is,  none  of  those  inter-tropical  countries 
can  boast  of  streams  and  water-courses  like  those  of  South  America." — 
"  The  Amazon,"  and  "  The  Atlantic  Slopes  of  South  America,"  by  M.  F. 
Maury,  LL.D.,  Lieutenant  U.  S.  Navy. 


MEDICAL  REPORT  5 

enormous.  Leaving  out  of  consideration  that  of  the 
Para  estuary  which  receives  the  Tocantins  and  several 
smaller  rivers,  the  discharge  of  the  Amazon  proper  is 
greater  than  that  of  the  Mississippi  and  Nile  combined, 
the  great  flood  converting  the  ocean  into  a  fresh  water 
sea  for  one  hundred  and  fifty  miles  from  the  coast.  This 
statement  is  based  on  estimates  made  of  the  outflow  at 
Obidos,  where  the  river  bed  is  constricted  between  high 
terra  firme  to  a  width  variously  estimated  at  one  and 
one  and  a  half  miles.  Wallace  made  his  estimate  of  the 
discharge,  750,000  cubic  feet  per  second,  by  taking  an 
average  depth  of  fifty  feet,  a  width  of  one  mile,  and  a 
current  of  four  miles  an  hour.  Herndon,  however,  has 
made  soundings  here,  showing  depths  of  one  hundred 
and  fifty,  one  hundred  and  seventy,  two  hundred  and 
ten  and  two  hundred  and  forty  feet,  and  the  great  rivers, 
Tapajos  and  Xingu,  enter  the  Amazon  stream  below 
Obidos.  Wallace  has  also  estimated  the  rainfall  of  the 
valley  and  finds  that  the  estimated  rainfall  1,500,000 
feet  per  second  corresponds  with  the  estimated  discharge 
estimating  the  evaporation  at  one-half  the  rainfall.^ 

The  color  of  the  Amazon  is  a  pale  cloudy  yellow;  the 
color  is  due  to  a  finely  divided  silt  which  precipitates 
slowly  and  imperfectly.  Many  of  the  tributary  streams 
have  the  same  character,  while  others  are  clear  and  of 
various  shades  of  amber,  and  these  are  known  as  the 
black  water  rivers,  -the  best  type  being  the  Rio  Negro.^ 

The  height  of  the  land  along  the  river  varies,  being 
much  lower  in  certain  places,  and  has  received  in  relation 

1  Estimates  play  a  predominating  part  in  all  descriptions  of  the  phj^sical 
features  of  South  America. 

2  "  Soon  afterwards  we  discovered  a  river,  on  the  left  hand,  with  water 
as  black  as  ink,  the  force  of  wliich  was  so  great  that  for  more  than  twenty 
leagues  its  waters  flowed  separately,  without  mingling  with  the  Amazons 
river."  - —  Orellana,  1539. 


6 


THE  RICE  EXPEDITION  TO  BRAZIL 


to  its  height  above  water  certain  designating  names. 
The  entire  low  region  subject  to  flood  is  known  as  the 
flood  plain,  and  this  is  divided  into  igapo  and  varzea. 
The  igapo,  really  a  swamp  forest,  (Fig.  1)  is  the  lowest 
land,  but  a  few  feet  above  the  mean  level,  and  is  subject 
to  overflow  by  the  tides  in  the  east  and  by  slight  rises  in 
the  river.     The  principal  area  of  the  igapo  is  the  flat 


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Fig.  1.     Igap6  on  lower  Amazon. 

coastal  region  east  of  Obidos.  It  is  a  country  of  islands 
separated  by  sluggish  but  often  deep  channels,  of  rivers 
and  of  lakes,  the  whole  unstable  and  constantly  chang- 
ing. The  varzea  is  the  higher  land  which  is  overflowed 
only  during  the  high  floods.  The  terra  firme  is  still 
higher  land,  which  is  not  subject  to  overflow.  All  of  the 
rivers  in  the  valley  have  igapo  and  varzea  on  both  sides 
of  them  and  extending  a  varying  distance,  broken  here 
and  there  by  higher  terra  firme.  The  terra  firme  rep- 
resents more  than  a  difference  in  altitude,  for  it  has  a 
clay  or  rock  foundation,  a  sand  surface  and  is  stable. 


MEDICAL  REPORT  7 

The  igapo  and  varzea  are  formed  of  alluvium;  the  land 
constantly  changing,  disappearing  in  one  place,  forming 
in  another;  large  islands  disappear  in  the  floods,  others 
are  formed,  igapo  becomes  varzea  and  vice  versa  (Figs. 
2  and  3).  While  on  the  way  to  Iquitos  we  saw  a  large 
section  of  the  bank  covered  with  high  forest  fall  into  the 
river  and  completely  disappear.  The  best  conception  of 
the  condition  is  gained  by  regarding  the  entire  flood 
plain  as  a  great  lake  which  has  been  filled  with  sediment 
until  only  the  rivers  remain. 

The  region  is  covered  with  forest,  in  extent  the  largest 
forest  in  the  world;  the  towns  and  the  clearings  in  it 
represent  merely  pin  pricks.  On  the  outskirts  of  the 
valley  there  are  great  regions,  known  as  campas,  free 
from  forest,  resembling  the  American  prairies  and  cap- 
able of  pasturing  immense  herds  of  cattle.  Wallace 
states  that  from  Tabatinga  on  the  border  of  Peru  a  circle 
can  be  drawn  with  a  radius  of  eleven  hundred  miles, 
all  of  which  will  be  within  the  forest.  Outside  of  this, 
smaller  circles  with  radii  up  to  four  hundred  miles  can 
still  be  included.  The  varieties  of  trees  and  the  density 
of  the  forest  vary  somewhat  in  different  regions,  but  the 
general  characteristics  are  the  same.  The  trees  are  tall 
and  closely  placed;  the  trunks  generally  smooth  and 
pale  in  color,  giving  off  no  branches  until  the  forest  roof, 
eighty  to  a  hundred  feet  above  the  ground,  is  reached. 
Above  this  roof  the  domes  of  many  of  the  higher  trees 
project.  Between  the  tall  trees  there  is  another  forest 
of  slender,  shade-loving  trees,  and  of  others  which  await 
an  opening  in  the  roof  through  which  to  get  their  heads 
into  the  light.  Vines  are  everywhere,  trailing  over  the 
ground,  extending  up  the  trunks  of  trees  and  as  long 
tightly  stretched  ropes  descending  from  the  trees  to 
the  earth.    Most  of  the  latter  are  the  aerial  roots  of 


8  THE  RICE  EXPEDITION  TO  BRAZIL 


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MEDICAL  REPORT  9 

parasitic  plants  which  hve  on  the  trees  high  up  in  the 
light.  The  tangle  of  vines  and  trees  is  densest  along  the 
banks  of  rivers  where  light  comes  from  the  sides  as  well 
as  from  overhead  and  here  the  forest  is  impenetrable. 
The  forest  yields  many  products,  the  most  important 
of  which,  commercially,  is  rubber.  Many  varieties  of 
trees  produce  a  form  of  rubber  but  the  best  is  obtained 
from  the  Hevea  Braziliensis  hj  making  incisions  in  the 
bark.  Much  of  the  timber  of  the  forest  is  of  great 
beauty  of  color  and  grain  and  has  come  into  some  use  in 
cabinet  work,  but  as  yet  the  forest  has  been  practically 
untouched.  Palms  are  found  in  all  regions,  but  the 
igapo  is  their  home,  and  they  are  found  here  in  many 
varieties,  some  of  them  the  largest  and  most  beautiful 
of  the  genus.  They  are  among  the  most  useful  trees  of 
the  forest;  the  fruit  of  many  is  of  value  as  food,  the 
leaves  are  used  for  thatching,  and  fibres  formed  from 
the  leaves  serve  the  purposes  of  flax. 

There  are  seasonal  variations  in  the  rainfall  forming 
a  long  wet  and  long  dry  season,  and  between  these  a 
short  dry  and  short  wet  season.  There  is  a  general  rise 
in  the  rivers  from  March  to  June,  with  a  slighter  rise  in 
December.  Notwithstanding  the  great  number  of 
rivers  and  their  depth,  they  are  insufficient  to  carry  off 
the  volume  of  the  water  which  falls  in  the  rainy  season 
and  the  entire  region  of  igapo  and  varzea  is  flooded. 
The  height  to  which  the  water  rises  in  the  floods  in  dif- 
ferent localities  varies  greatly  and  seems  to  upset  the 
laws  of  hydrostatics.  This  is  due  to  many  conditions, 
the  most  important  being  the  general  flatness  of  the 
region  and  the  great  tortuosity  of  the  rivers.  In  the 
eastern  end  the  flood  rains  come  two  months  earlier 
than  in  the  west;  and  in  the  northern  part,  which  is 
drained  chiefly  by  the  Rio  Negro,  the  rains  are  inter- 


10 


THE  RICE  EXPEDITION  TO  BRAZIL 


mediate.  The  rise  in  some  places  is  enormous.  At 
Manaos  the  maximal  rise  is  a  hundred  feet  and  the  usual 
forty  to  fifty.  The  valley  becomes  a  vast  sea  and  canoes 
pass  through  the  forest.  The  inhabitants  of  the  low 
lands  take  to  boats  or  withdraw  to  the  terra  firme  and 
thousands  of  cattle  are  drowned  each  year  (Fig.  4) .  The 
flood  is  the  time  of  scarcity  owing  chiefly  to  the  wider 
distribution  of  the  fish  which  renders  their  capture  diffi- 

Jan.      Feb.    March    April    May      June      July       Aug.      Sept.      Oct.      Nov.     Dee.     Jan.       Feb. 


.  =  1914 
-  =  191.5 


1914,  Total  Rainfall  1821  mm.  =  73  inches 

1915,  "  "         2266  mm.  =  91  inches 


Fig.  3a.     Rainfall  at  Manaos,  1914-1915. 


cult,  and  the  deprivation  of  the  land.  Mosquitoes  and 
fever  are  more  common  at  the  end  of  the  rainy  season. 
Even  during  the  wet  season  the  rain  is  not  continu- 
ous, it  comes  usually  in  the  afternoon  and  is  often  of 
great  intensity.  The  rainfall  at  Manaos  for  1915  was 
ninety-one  inches,  and  seventy-three  inches  for  1914. 

The  prevailing  wind  is  in  the  direction  of  the  trades, 
from  east  to  west,  and  there  is  in  general  little  wind 
movement.  Storms  are  rare,  of  short  duration,  and  local 
in  their  effects.    The  forest  rarely  shows  tracks  of  storm, 


MEDICAL  REPORT  11 

and  for  the  most  part  in  the  early  morning  and  evening 
the  waters  show  as  perfect  a  mirror  as  a  mountain  lake. 
Throughout  this  vast  region  communication  is  by 
water  only;  the  rivers  and  tributary  streams  are  so 
numerous  that  a  large  area  is  accessible.  There  are  also 
many  communicating  streams  between  the  rivers  and 
lakes,  open  to  steamer  navigation.  Extending  from  the 
rivers  there  are  everywhere  igarapes  or  canoe  paths, 
which  pass  for  long  distances  into  the  land.    The  extent 


Fig.  4.    Terra  firme.    A  sitio  or  plantation  on  the  Autaz  River. 

of  these  waterways  may  be  seen  from  the  map  (Fig.  5), 
which  represents  a  small  region  above  Monte  Alegre; 
and  the  region  of  the  Autaz  river  south  of  the  Amazon 
through  which  one  of  us  passed  is  very  similar.  There 
are  no  railroads  in  the  region  and  no  roads  to  be  tra- 
versed by  horse  or  vehicle  save  in  the  immediate  vicinity 
of  the  larger  cities  and  towns.  Shallow  draught 
steamers,  usually  propelled  by  a  stern  wheel  and  using 
wood  for  fuel,  make  trips  to  the  head  of  navigation  on 
the  various  rivers,  the  trip  often  taking  several  weeks. 
Most  of  these  steamers  are  owned  by  English  companies 


12  THE  RICE  EXPEDITION  TO  BRAZIL 

and  have  headquarters  in  Para,  Manaos,  and  in  Iquitos. 
In  addition  to  the  steamers,  launches  ply  on  the  smaller 
streams,  using  kerosene  for  fuel.  The  steamers  we  have 
seen  were  comfortable,  the  food  good  and  more  than 
abundant.  The  region  between  the  rivers  is  for  the  most 
part  unknown  and  inaccessible.  There  have  been 
hazardous  explorations  in  certain  regions,  and  paths 
made  by  Indians  and  rubber-gatherers  extend  inward 
for  short  distances  only. 

The  valley  of  the  Amazon  is  the  most  unchanged  and 
unchanging  great  region  on  earth.  It  presents  the  same 
features  as  it  did  in  1539  when  Orellana,  deserting  his 
commander,  first  came  down  the  great  river  from  the 
Kingdom  of  Quito,  the  Ecuador  of  today,  and  the  descrip- 
tion of  the  life  of  the  Indians  given  by  Acuna  a  hundred 
years  later  holds  with  few  exceptions  for  today. 

It  is  a  solitary  region  and  the  longing  of  the  poet  "  for 
a  lodge  in  some  vast  wilderness  "  could  be  easily  grati- 
fied. The  usual  estimate  of  the  population  is  one  to  the 
square  mile,  but  there  is  no  accurate  knowledge  of  the 
population,  nor  whether  it  is  increasing  or  diminishing. 
Judging  from  Acuiia's  narrative  in  which  he  describes 
the  villages  along  the  Amazon  as  forming  an  almost  con- 
tinuous line,  it  is  diminishing.  There  has  been  some 
increase  in  the  population  of  such  cities  as  Para,  Manaos, 
and  Iquitos,  but  the  population  of  the  smaller  towns, 
especially  along  the  Rio  Negro,  is  said  by  the  best  in- 
formed to  be  diminishing,  and  there  is  further  evidence 
of  this  in  the  ruins  of  houses  and  churches.  It  is  possible 
to  travel  in  a  steamer  for  an  entire  day  without  seeing  a 
human  habitation.  The  population  is  on  the  highway 
of  the  water  courses.  Here  are  the  towns  which  with  the 
exception  of  the  cities  of  Para,  Manaos,  and  Iquitos,  are 
of  small  size,  rarely  exceeding  a  thousand  inhabitants. 


14 


THE  RICE  EXPEDITION  TO  BRAZIL 


There  is  some  confusion  in  the  statements  regarding 
population  in  that  the  town  includes  an  entire  district 
of  many  square  miles.  There  are  sparse  villages  com- 
posed of  palm  thatched  huts  and  scattered  single 
huts  (Fig.  6) .  Many  of  the  towns  and  villages  as  seen 
from  the  river  are  exceedingly  picturesque,  situated  as 
they  generally  are  on  high  land  with  areas  of  grazing 
land  about  them,  on  which  a  number  of  forest  trees  of 


Fig.  6.     San  Gabriel  on  the  upper  Rio  Negro.    This  is  at  the  first 
rapids  and  was  formerly  a  trading  station  of  importance  and 

there  ARE  RUINS  OF  A  FORT  WITH   SEVERAL  ANCIENT   GUNS. 

great  height  and  size  have  been  allowed  to  remain  when 
the  land  was  cleared.  There  are  many  palms,  single  and 
in  groups,  and  in  the  gardens  around  the  houses  are  the 
broad  leafed  banana,  pawpaw,  bread  fruit,  and  citrous 
trees. 

Indians  compose  the  bulk  of  the  population  and 
although  divided  into  many  tribes  have  a  more  or  less 
interrelated  language  and  common  physical  character- 
istics.   They  are  generally  short  and  heavily  built,  the 


MEDICAL  REPORT 


15 


Fig.  7.     Plantation  Indians.     Attached  to  a  rubber  plantation  on  the 

Rio  Negro. 


Fig.  8. 


Forest  Indians  of  the  Macu  tribe.    This  is  a  low-caste  ensl.\ved 

TRIBE  ON  the  RiO  NeGRO. 


16  THE  RICE  EXPEDITION  TO  BRAZIL 

chest  large  and  muscular,  the  arms,  owing  to  their  being 
a  canoe  people,  more  developed  than  the  legs  (Figs.  7 
and  8).  There  is,  however,  much  variation  in  the  dif- 
ferent tribes.  The  color  is  rather  paler  than  that  of  the 
North  American  Indians,  No.  4  of  Brocas  scale,  the 
cheek  bones  not  so  high  and  prominent,  the  eye  slits 
narrow  and  the  whole  cast  of  countenance  is  more  of 
the  Asiatic  than  the  North  American  type.  The  hair 
of  the  male  is  abundant,  coarse,  straight,  and  black, 
lacking  on  the  face  and  body.  The  hair  of  the  female 
is  abundant  and  much  finer.  Depilation  of  the  body  is 
practiced  by  both  sexes. ^ 

The  Indians  in  all  accessible  regions  are  practically 
enslaved  by  the  rubber  merchants,^  who  have  obtained 
from  the  government  concessions  of  the  land.  They 
have  become  increasingly  dependent,  their  agriculture 
and  arts  are  being  lost,  and  they  receive  for  their  labor 
rum,  sewing  machines,  music  boxes,  and  other  useless 
products  of  civilization.  They  are  in  general  a  non-war- 
like, patient,  and  docile  race,  not  lacking  in  intelligence, 
and  these  very  qualities  render  their  exploitation  the 
more  easy.  In  places  remote  from  civilization  dreadful 
atrocities  have  been  perpetrated,  dwellings  burned,  men 
killed,  women  and  children  carried  off.  The  remote 
Indians,  in  regions  where  the  toils  of  the  rubber  exploita- 
tion have  not  extended,  live  in  maloccas,  or  community 
houses,  hidden  in  the  depths  of  the  forest,  and  reached 
by  concealed  paths  which  extend  from  a  river  or  a  small 
stream  navigable  only  for  a  canoe.  The  maloccas  are 
often  of  great  size,  sheltering  as  many  as  two  hundred 

^  It  is  quite  striking  how  rarely  one  sees  baldness  in  either  whites  or 
Indians  in  this  part  of  Brazil,  with  the  exception  of  the  foreigners. 

^  The  Indians  represented  in  Fig.  8  are  women  from  an  inferior  tribe 
of  forest  Indians  who  with  their  driver  were  on  their  way  to  the  rubber 
regions. 


MEDICAL  REPORT  17 

inmates  and  are  cleverly  constructed  of  beams  and  poles 
lashed  together  with  vines  and  covered  with  palm 
thatch.  Within  the  common  dwelling  each  family  has 
its  own  fireside  and  independent  life,  the  social  organiza- 
tion resembhng  the  "long  house"  of  the  Iroquois.  There 
are  cleared  plantations  in  the  vicinity  of  the  malocca, 
the  care  and  cultivation  of  which  is  entrusted  to  the 
women,  while  the  men  prepare  the  ground  by  cutting 
down  and  burning  the  forest,  hunt,  fish,  and  rest  from 
their  labor.  Certain  of  the  customs  are  also  to  the 
advantage  of  the  male,  as  when  a  woman  gives  birth  to 
a  child  the  father  goes  through  a  period  of  rest  in  his 
hammock  and  receives  delicacies  and  congratulations. 
Inter-tribal  wars  are  common  and  have  been  one  of  the 
means  of  depleting  their  numbers. 

Apart  from  the  Indians  the  population  is  a  hetero- 
geneous mixture.  The  Brazilian  population,  originally 
Portuguese,  has  interbred  freely  with  both  negroes  and 
Indians,  the  Indian  half-breed  mameluco  being  as  a 
rule  superior  to  the  mulatto.  There  is  a  steady  immi- 
gration of  Portuguese  who  form  an  industrious,  hard 
working  population,  and  do  most  of  the  work.  The 
population  in  the  cities  is  extraordinarily  varied,  for  the 
wealth  coming  from  the  rubber  industry  has  attracted 
immigrants  from  the  entire  world  and  every  nationality 
is  represented  among  the  prominent  rubber  merchants. 
As  in  other  places,  certain  trades  fall  into  the  hands  of 
different  nationalities;  the  sale  of  dry  goods  by  peddling 
is  in  the  hands  of  the  Armenians,  and  the  very  extended 
trade  of  prostitution  is  chiefly  conducted  by  the  Poles. 
Few  of  the  whites,  except  those  of  the  lowest  class, 
engage  in  the  actual  collection  of  rubber  or  other  forest 
products.  On  the  land  the  whites  generally  live  in  vil- 
lages or  on  large  estates.     The  houses  of  these  estates 


18  THE  RICE  EXPEDITION  TO  BRAZIL 

are  situated  on  prominent  points  of  the  rivers  and  sur- 
rounded by  offices  and  farm  buildings;  life  in  many  of 
these  is  on  a  feudal  scale  and  a  wide  and  generous 
hospitality  is  dispensed. 

In  addition  to  rubber  the  region  produces  gutta 
percha,  sarsaparilla,  tobacco,  sugar,  cacao,  mandioca, 
piassaba  fibre,  nuts,  and  a  variety  of  forest  products, 
among  them  many  valuable  drugs.  The  chief  exports, 
are  rubber,  nuts,  and  sarsaparilla.  The  great  wealth 
of  the  region,  which  has  hardly  been  touched,  lies  in 
the  timber,  and  as  a  source  of  natural  wealth  this  can 
hardly  be  destroyed.  There  are  many  difficulties  which 
lie  in  the  way  of  its  exploitation,  the  chief  of  these  being 
the  great  variety  of  the  growth.  All  of  the  wood  has 
value  as  timber  but  the  character  differs  so  greatly  that 
the  unsorted  lumber  could  not  be  used  for  a  common 
purpose  not  even  for  the  production  of  wood  pulp. 
Doubtless,  however,  the  time  is  approaching  when  the 
demand  for  lumber,  with  the  rapidly  decreasing  supply, 
will  compel  the  world  to  draw  upon  this  seemingly 
inexhaustible  source. 

Life  in  the  region  is  primitive  in  the  extreme.  Almost 
every  house  has  a  small  plantation  of  mandioca  {manihot 
utilissima)  which  forms  the  staple  food.  The  roots  of 
this,  after  being  thoroughly  washed  and  soaked,  are 
grated  on  a  rude  grater  of  wood  into  which  small  sharp 
pebbles  are  inset,  the  mass  of  pulp  is  again  steeped  in 
water  and  the  juice,  which  contains  a  poisonous  prin- 
ciple, expressed.  The  resultant  material  is  then  dried 
or  baked  in  a  rude  oven  and  crushed  into  grains  of  vary- 
ing fineness.  There  are  several  varieties  of  the  plant 
and  the  products  differ  correspondingly.  It  is  eaten 
mixed  with  other  foods  or  stirred  in  water  to  a  thin 
gruel.    In  certain  regions  maize  is  used  in  the  same  ways 


MEDICAL  REPORT  19 

as  by  the  North  American  Indians.  No  flour  is  made  in 
the  region,  all  of  this  or  its  products  being  imported. 
Coffee  and  cacao,  the  latter  in  large  amount,  are  also 
produced.  Save  in  the  cities  and  on  the  large  estates 
meat  enters  but  little  into  the  food.  Fish  are  abundant 
in  the  rivers  and  of  excellent  quality,  turtles  are  numer- 
ous and  with  their  eggs,  which  are  collected  in  large 
quantities,  constitute  one  of  the  staple  foods.  Although 
great  numbers  of  cattle  are  raised  on  some  of  the  rivers, 
milk  and  dairy  products  except  in  the  form  of  cheese, 
are  rarely  seen  beyond  the  plantations.  The  principal 
vegetables  outside  of  the  universal  mandioca  are  yams, 
beans,  sugar  cane,  maize,  and  rice.  Cabbage,  which 
grows  rapidly  and  never  forms  heads,  melons,  small  and 
inferior,  peppers  in  great  variety  of  size,  form,  and  pun- 
gency, are  also  raised  in  the  gardens.  Pigs  are  found 
almost  in  a  wild  state  about  the  villages  and  houses; 
they  live  on  the  offal,  the  wild  fruit,  and  nuts  and  receive 
no  care  save  an  occasional  scattering  of  corn.  Chickens 
also  form  a  part  of  the  domestic  animals.  Nearly  every 
house  has  about  it  a  few  fruit  trees;  bananas,  pine- 
apples, oranges,  mangoes,  pawpaw,  alligator  pears,  and 
bread  fruit  are  the  most  common;  the  pupunha,  or  peach 
palm,  the  fruit  of  which  is  delicious  and  nutritive,  the 
cucura,  whose  fruit  is  borne  in  clusters  and  resembles 
in  flavor  the  black  Hamburg  grape,  are  less  common. 
Cattle  are  not  found  save  about  the  large  plantations 
and  villages  where  there  are  areas  of  grazing  lands. 
With  a  very  slight  expenditure  of  toil  an  abundance  of 
food  of  excellent  quality  is  produced. 

A  sort  of  beer  is  made  by  the  fermentation  of  both  the 
sugar-cane  juice,  maize,  and  mandioca,  but  the  general 
intoxicant  all  over  the  country  is  cachaca  or  rum,  which 
is  made  and  used  everywhere.    The  rum  is  white,  of 


20  THE  RICE  EXPEDITION  TO  BRAZIL 

inferior  quality  and  is  used  generally  fresh  from  the  still. 
There  is  no  government  tax  upon  the  product  nor  regu- 
lation of  its  sale.  It  has  been  the  principal  means  by 
which  the  degradation  of  the  Indians  has  been  brought 
about  and  to  its  unrestricted  use  the  general  low  stage 
of  development  of  the  entire  region  is  to  be  largely 
attributed.  In  addition  to  these  alcoholic  drinks  coca 
and  guarana,  the  latter  containing  a  large  amount  of 
caffein,  are  used  as  stimulants. 

In  spite  of  the  enormous  tree  growth  covering  the 
land,  clearing  is  not  very  difficult  and  owing  to  the  rich- 
ness of  the  soil  and  the  combination  of  this  with  heat 
and  moisture,  growth  of  all  sorts  is  so  luxuriant  that 
a  small  area  will  produce  a  large  amount  of  food.  In 
clearing,  all  except  the  largest  trees  are  felled  and  the 
immense  mass  of  tangle  which  results  is  burned,  taking 
days  or  weeks,  and  although  the  smaller  trunks  and 
vines  are  consumed  the  great  fallen  trunks  remain  until 
the  more  thorough  work  of  fungi  and  ants  causes  their 
disappearance.  The  thickness  of  the  bark  of  the  great 
trees  which  are  left  standing  protects  them  from  the 
effect  of  the  fire.  These  noble  trees  in  a  pasture  of 
closely  cropped  fine  thick  grass,  at  all  times  a  vivid 
green,  with  fine  cattle  standing  in  the  grateful  shade 
given  by  the  crown  of  foliage  often  a  hundred  feet  above, 
and  with  towering  palms,  single  or  in  groups,  which 
always  seem  to  seek  a  situation  with  an  eye  to  the 
picturesque,  form  a  sight  never  to  be  forgotten. 

Mammalian  life  is  not  abundant  in  the  forest  save  in 
areas  away  from  the  rivers,  and  even  edible  birds  are 
comparatively  rare;  though  geese,  ducks,  and  snipe  are 
abundant  along  the  upper  waters  of  some  of  the  rivers. 
With  the  exception  of  the  herons,  the  interesting  non- 
edible  ciganas,  the  parrots  and  macaws,  and  the  two  or 


MEDICAL  REPORT  21 

three  common  varieties  of  small  birds,  such  as  parroqiiets 
and  troupials,^  all  of  which  are  seen  along  the  rivers  or  in 
clearings,  the  traveller  rarely  sees  a  bird.  In  the  forest 
they  may  be  present  but  they  live  in  the  high  roof  in- 
visible to  the  untrained  eye.  Of  edible  mammals  there 
are  tapirs,  wild  hogs  or  peccaries,  monkeys,  small  deer, 
armadillos,  and  a  few  smaller  animals  of  the  rodent 
family.  Starvation  awaits  every  individual  who  at- 
tempts to  live  from  the  products  of  the  wilderness,  if 
away  from  the  rivers.  Much  of  the  life  is  inimical  or 
certainly  unfriendly  to  man.  Of  dangerous  beasts  the 
jaguar  only  deserves  mention,  and  though  there  are 
records  of  an  unprovoked  attack  on  man,  the  cases  are 
so  rare  as  to  be  negligible.  There  are  very  few  danger- 
ous and  poisonous  serpents.  The  boa  constrictor  is  very 
rare,  but  has  been  known  to  attack  man;  and  of  the 
poisonous  reptiles  the  most  common  are  the  jacaraca, 
the  rattlesnake,  and  the  coral  snake,  all  more  common 
in  the  uplands  than  in  the  river  forests. 

The  Insects 

It  is  when  we  come  to  the  insects  that  the  real  ene- 
mies of  man  are  encountered.  They  are  the  masters  of 
the  wilderness  and  they  seek  to  extend  their  dominion 
over  all  w^ho  intrude.  The  most  ubiquitous  are  tlie  ants. 
No  region,  no  home  is  free  from  them,  whether  in  city 
or  country,  in  forest  or  clearing.  So  far  as  can  be  ascer- 
tained, though  troublesome  and  unpleasant,  tliey  con- 
vey no  diseases.  One  of  them,  gigantic  in  size,  an  inch  or 
more  in  length,  the  Tucandera  or  conga,  is  found  chiefly 

^  The  troupials  give  an  interesting  example  of  the  use  of  a  protective 
environment.  The  colonies  of  their  long  dependent  nests  are  placed  on 
trees  which  also  contain  the  homes  of  the  most  venomous  wasps  of  the 
region  thus  ensuring  protection  of  the  eggs  from  the  monkeys. 


22  THE  RICE  EXPEDITION  TO  BRAZIL 

in  the  forest,  produces  great  pain  and  prostration  by 
its  sting,^  and  instances  have  been  known  of  a  number 
of  bites  resulting  fatally.  These  ants  never  invade  the 
houses.  There  is  a  small  variety,  well  named  "fire  ant" 
from  the  effect  of  its  sting,  which  has  sometimes  invaded 
villages  and  driven  the  inhabitants  away.  There  are 
also  armies  of  foraging  ants  which  destroy  everything 
which  comes  in  their  way.  The  most  interesting  are  the 
Saiiba  or  leaf -cutting  ants  which  carry  sections  of  leaves 
to  their  nests  along  narrow  smooth  paths  which  they 
form  in  the  forest  and  fields.  This  material,  after  under- 
going a  preparation  by  chewing,  provides  a  soil  on  which 
a  fungus,  which  serves  them  for  food,  is  grown.  They 
select  only  certain  trees  for  their  depredations  and  are 
particularly  fond  of  trees  foreign  to  the  region  and  which 
are  cultivated,  such  as  the  cacao  tree.  The  planter  must 
wage  a  continuous  warfare  against  them  and  they  often 
show  great  ingenuity  and  perseverance  in  circumventing 
man's  efforts.  Nearly  every  flower  which  blooms  in  the 
forest  contains  ants  which  seek  the  nectar  and  some  even 
have  entered  into  neighborly  relations  with  plants  and 
are  of  mutual  assistance. 

^  Spruce,  vol.  i,  says  of  the  Tucandera  ants:  "It  was  about  2.00  p.m. 
when  I  was  stung  and  I  experienced  no  alleviation  of  the  pain  until  5.00. 
During  all  this  time  my  sufferings  were  indescribable,  I  can  only  liken  the 
pain  to  that  of  a  hundred  thousand  nettle  stings.  My  feet,  and  sometimes 
my  hands,  trembled  as  though  I  had  the  palsy,  and  for  some  time  the  per- 
spiration ran  down  my  face  from  the  pain.  With  difficulty  I  repressed  a 
strong  inclination  to  vomit.  I  took  a  dose  of  laudanum  at  four  and  I  think 
this  did  more  than  anything  to  lull  the  pain.  I  had  been  stung  on  the  two 
big  toes,  but  the  stings  which  caused  me  most  suffering  were  four  close 
together  among  the  fine  veins  below  the  left  ankle.  When  the  pain  of  all 
the  others  had  subsided  this  continued  to  torment  me  and  pains  shot  from 
it  all  over  the  forefoot  and  up  the  leg,  in  spite  of  the  bandages.  The  pain 
returned  with  great  force  at  nine  o'clock,  and  at  midnight,  and  each  time 
caused  me  an  hour  of  acute  suffering.  The  next  morning  there  was 
numbness  and  the  inflammation  continued  for  thirty  hours." 


MEDICAL  REPORT 


23 


They  excavate  long  tunnels  in  the  earth,  which  extend 
with  communications  for  hundreds  of  feet,  they  throw 
up  long  mounds  of  earth  several  feet  in  height,  they  form 
great  nests  high  up  in  trees  with  covered  galleries  leading 
to  them,  or  an  entire 
tree  trunk  or  house 
side  may  be  covered 
with  shaggy  masses  of 
material  which  form 
their  home  (Fig.  9). 
Many  species  are 
winged  and  form  their 
nests  high  up  in  trees 
without  communica- 
tion with  the  earth. 
Their  sting  resembles 
the  thrust  of  a  red 
hot  needle  into  the 
skin  and  though  pain- 
ful for  the  moment 
leaves  no  unpleasant 
after-effect.  The  skin 
is  blanched  over  a 
small  area  immedi- 
ately around  the  sting 
and  a  firm  induration 
forms  which  shortly 
passes  away.  It  is  possible  that  in  very  tender  skins 
vesicles  may  be  formed  by  the  exudate.  In  a  house 
on  the  Autaz  river  small  vesicles  and  superficial  ero- 
sions were  seen  on  the  bare  feet  and  legs  of  a  child  of 
four  years,  which  the  father  said  were  caused  by  the 
stings  of  small  brown  ants,  numbers  of  which  were  seen 
running  about  the  floor.     None  of  the  other  members 


Fig.  9.    Tree  trunk  covered  with  the 

SHAGGY   masses   OF   ANTS'    NESTS. 


M  THE  RICE  EXPEDITION  TO  BRAZIL 

of  the  family  were  so  affected,  although  frequently 
stung. 

There  are  also  legions  of  wasps,  many  of  them  of  great 
size  and  extremely  venomous,  who  construct  nests  of 
complicated  design,  but  who  fortunately  have  as  yet 
not  learned  to  prey  upon  man,  and  with  care  can  be 
avoided. 

All  travellers  in  the  region  regard  the  pium,  a  small 
biting  fly,  as  a  most  troublesome  insect.  These  are  not 
more  than  2-3  mm.  in  length  and  1/2  mm.  in  breadth, 
the  underside  of  the  body  is  pale,  the  back  black  with  a 
small  glistening  point  between  the  wings  which  are  not 
closely  folded.  The  insect  is  extraordinarily  active  and 
its  destruction  or  capture  not  easy  to  attain.  It  alights, 
runs  around  quickly  until  it  finds  a  suitable  spot,  then 
quickly  bites  and  fills  with  blood,  and  only  when  in  the 
act  of  sucking  is  capture  possible.  A  hard  swelling, 
5  mm.  in  diameter  and  2  mm.  in  height,  is  produced  and 
in  the  centre  of  this  is  a  perfectly  round  spot  of  hemor- 
rhage 1/2  mm.  in  diameter.  The  itching  is  intense  and 
when  the  bites  are  numerous  there  may  be  considerable 
diffuse  oedema,  due  probably  to  the  combination  be- 
tween bites  and  scratching.  Protection  can  be  attained 
only  by  close  meshed  head  nets  and  gloves;  citronella 
oil  is  efficacious  for  a  time  but  must  be  frequently 
renewed  and  is  itself  irritating  to  some  skins.  The 
piums  are  not  widely  distributed.  The  head  waters  of 
the  black  water  rivers  are  favorite  localities  and  the  Rio 
Negro  and  Casiquiare  Canal  have  enjoyed  an  unpleas- 
ant notoriety  in  this  regard.  They  are  confined  to  the 
banks  of  the  rivers  and  are  never  seen  in  the  adjoining 
forest.  They  were  very  numerous  and  troublesome 
when  we  were  camped  at  Camanaos,  just  below  the 
rapids  of  San  Gabriel,  and  it  was  a  great  relief  to  pass 


MEDICAL  REPORT  25 

from  the  heat  and  glare  of  the  sand  })ar  into  the  cool 
twihght  of  the  forest,  where  the  only  insects  were  the 
ants.  The  areas  on  the  rivers  most  favored  by  the 
piums  are  shores  of  sand  bars  and  rocks  with  swift  cur- 
rent; they  may  be  in  great  numbers  in  one  locality  and 
absent  in  another,  although  the  same  conditions  may  be 
present.  There  is  no  acquired  immunity  to  the  effect  of 
their  bites,  natives  and  Indians  suffering  equally  with 
strangers.  There  is  a  very  general  belief  that  the  irrita- 
tion following  the  bite  may  be  lessened  by  puncturing 
the  small  spot  of  hemorrhage  and  squeezing  out  the 
blood  which  lies  in  a  small  cavity  in  the  corium,  but  like 
many  therapeutic  procedures  it  does  not  prove  effective. 
The  pium  is  a  day  insect,  arising  promptly  with  the 
sun  and  most  active  in  the  early  morning  after  the  repose 
of  the  night.  There  is  a  very  general  belief  that  the 
very  common  ulcers  seen  in  the  region  are  produced  by 
them,  but  in  the  absence  of  experimental  evidence,  this 
may  be  questioned.  We  found  no  typical  Leishmania 
ulcers  in  the  natives  of  the  regions  where  the  piums 
were  most  abundant.  At  San  Isabel  the  storekeeper  was 
so  severely  bitten  that  the  bare  feet  and  ankles  looked 
as  though  black  pepper  had  been  sprinkled  upon  the 
skin.  There  was  also  some  diffuse  oedema,  vesicle  for- 
mation, suppuration  and  superficial  ulceration,  but  the 
condition  bore  no  resemblance  to  the  Leishmania  ulcer, 
and  responded  readily  to  cleanliness  and  simple  treat- 
ment. The  habit  of  stockings  would  be  a  valuable 
innovation  where  the  piums  abound. 

More  tormenting  even  than  the  piums  are  the 
micuims.^    These  are  so  small  as  to  be  just  visible  to 

1  This  insect,  whose  Ufe  history  is  known  not  at  all  or  imperfectly,  is  a 
larval  form  of  a  species  of  Trombididea.  It  has  received  different  names  in 
the  various  places  where  found,  and  the  name  here  used  is  probably  a  per- 


26  THE  RICE  EXPEDITION  TO  BRAZIL 

the  naked  eye  when  on  a  surface  of  contrasting  color. 
They  are  a  bright  orange  in  color  and  when  collected  on 
a  white  stocking  this  looks  as  though  covered  with  red 
pepper.  They  move  with  such  rapidity  over  the  skin 
that  it  is  difficult  to  keep  one  within  the  field  of  a  lens, 
and  having  selected  a  point  they  quickly  penetrate 
within  the  epidermis  by  a  boring  motion,  the  insect  con- 
stantly turning.  No  irritation  is  felt  at  the  time,  but 
shortly  great  indurated  wheals  several  centimeters  in 
diameter  are  formed,  often  with  a  small  vesicle  in  the 
centre,  and  the  itching  is  intense.  No  other  experience 
can  be  compared  with  it,  and  it  seemed  impossible  that 
an  insect  so  small  could  have  such  an  effect.  The  insect 
could  frequently  be  recovered  just  within  the  epidermis 
in  the  centre  of  the  wheal,  but  there  was  no  evidence 
that  ova  were  deposited  nor  did  they  seem  to  undergo 
here  any  further  metamorphosis.  They  are  very  gen- 
erally distributed  throughout  the  region,  chiefly  in  the 
pastures,  and  are  much  worse  in  the  dry  than  in  the  wet 
season.  They  attack  the  cattle  who  do  not  seem  to  be  at 
all  bothered  by  them,  and  it  seems  probable  that  man  is 
only  occasionally  a  prey  and  the  peculiarly  virulent 
character  of  their  poison  is  not  really  meant  for  man  but 
to  reach  through  the  far  thicker  epidermis  of  the  cattle 
who  may  have  some  additional  protection  in  a  partial 
acquired  immunity.  In  man  there  seems  to  be  consider- 
able individual  variation  in  susceptibility  to  their  effects. 
The  two  individuals  of  our  party  who  suffered  most 
were  blonds,  but  at  the  same  time  these  were  most  ex- 
posed, one  by  his  work  of  erecting  stations  for  wireless 
operation  and  the  other  from  his  habit  of  wandering 

version  of  Mouqui,  by  which  it  is  known  in  Peru.  It  is  soft-bodied,  with 
six  legs  provided  with  claws  and  has  a  powerful  hypostoma  which  it  drives 
into  the  skin. 


MEDICAL  REPORT  27 

over  the  fields  to  satisfy  curiosity.  They  are  much  more 
numerous  in  certain  places  than  in  others,  and  in  the 
older  pastures  rather  than  in  the  newly  acquired.  At 
one  large  sitio  where  we  spent  several  days  it  was  neces- 
sary to  cut  paths  in  the  turf,  leading  from  the  house  to 
the  various  farm  buildings,  and  the  family  was  anxious 
to  sell  the  property  and  move  away  on  account  of  them. 
There  is  no  protection  against  them,  for  they  can  easily 
find  their  way  to  the  interior  through  the  openings  of 
clothing  or  even  pass  directly  through  it.^  The  areas 
of  skin  most  attacked  were  the  waist  region,  the  but- 
tocks, and  the  thighs,  they  seeming  to  select  those  parts 
least  susceptible  to  scrutiny.  They  can  be  partly 
avoided  by  removing  all  the  clothing  when  coming  from 
a  walk  and  washing  the  body  in  strong  rum,  which  kills 
the  insects  in  contact  with  it.  We  found  that  the  best 
means  of  allaying  the  intolerable  itching  was  an  appli- 
cation of  corrosive  sublimate,  1-1000. 

Of  much  less  importance  than  these  two  main  pests 
are  the  meruim,  a  tiny  fly  much  resembling  the  gnat  of 
Canadian  rivers,  which  bites  but  leaves  no  effect,  and  the 
matuca  which  bites  fearlessly  and  fiercely  both  animals 
and  man,  but  which  is  not  poisonous.  Scorpions  and 
centipedes  are  numerous  in  some  places,  but  we  did  not 
encounter  them.  Spiders  are  numerous  but  did  not 
seem  to  be  harmful. 

There  are  some  compensations.  The  ordinary  house 
fly  is  absent,  nor  do  carrion  flies  seem  to  be  present. 
During  our  residence  in  San  Gabriel  swarms  of  small 
black  flies  were  attracted  by  sugar  spilled  on  the  floor, 
but  they  were  not  troublesome,  and  like  dinner  guests 

^  High  boots  give  no  protection,  for  they  quickly  pass  beyond  the  tops 
of  these.  It  is  not  improbable  that  some  measure  of  protection  might  be 
gained  by  a  band  of  some  sticky  material  around  the  boot  just  as  trees  are 
protected  against  the  ascent  of  gypsy  moth  caterpillars  by  such  a  band. 


28  THE  RICE  EXPEDITION  TO  BRAZIL 

disappeared  after  the  feast.  All  conditions  seemed  to 
be  present  which  would  favor  the  life  of  the  house  fly 
and  it  seemed  to  us  that  probably  the  reason  for  their 
absence  lay  in  the  destruction  of  their  larvae  by  ants. 
So  far  as  I  know,  however,  no  proof  of  this  has  been 
shown.  There  are  no  privies  in  the  region  save  in  the 
cities,  but  about  the  houses  and  villages  there  is  little 
or  no  evidence  of  soil  pollution,  all  faeces  being  removed 
by  the  ants  in  a  few  hours. ^  In  the  pastures  also  the 
large  faecal  masses  from  the  cattle  remain  but  a  short 
time  and  the  small  grass  clumps  which  in  our  pastures 
denote  past  deposits  are  not  seen.  On  the  river  banks 
the  cattle  often  lie  in  the  warm  sand  at  night,  and  here 
where  ants  are  absent  the  faeces  remain  until  they  dry 
up.  Although  dead  animals  must  be  not  uncommon, 
there  is  no  smell  of  carrion,  for  the  buzzards  and  ants 
quickly  care  for  a  carcass.  There  are  no  flies  in  the 
pastures  to  bother  the  cattle,  which  to  some  extent  ac- 
counts for  their  good  appearance  and  apparent  content- 
ment. The  matuca,  which  does  bite  them,  is  confined 
to  the  river  shores.  We  have  never  seen  mosquitoes 
about  them,  though  possibly  as  the  mosquito  here  is  a 
nocturnal  insect  they  may  bite  them  at  night. 

It  is  interesting  in  placing  insects  in  the  order  of 
importance  of  their  immediately  unpleasant  effects  that 
the  mosquito  should  come  last.  The  yacht  was  thor- 
oughly screened,  but  on  the  long  voyage  up  the  Amazon 
and  return,  during  a  great  part  of  which  both  luncheon 
and  dinner  were  served  on  the  open  deck,  they  were 
practically  absent  save  on  one  or  two  occasions  on  the 
upper  river  when  we  were  at  anchor  close  to  the  bank. 

^  The  rarity  of  typhoid  fever  in  the  cities  and  its  practical  absence  in 
the  country  may  also  be  due  to  the  action  of  the  ants  as  general  scav- 
engers. However,  even  if  this  be  true,  it  is  a  large  price  to  pay  for 
immunity. 


MEDICAL  REPORT  29 

In  the  cities  we  never  saw  them  during  the  day  but  in 
the  hotel  at  Manaos  I  was  several  times  bitten  at  night, 
though  under  a  mosquito  bar.  We  have  many  times 
been  along  the  river  shores  in  swampy  land,  partly  over- 
flowed, on  shallow  lakes,  in  short  in  many  places  where 
similar  conditions  with  us  would  have  made  such  excur- 
sions martyrdoms,  without  seeing,  hearing  or  feeling  a 
mosquito.  On  the  river  boat  which  conveyed  us  from 
Manaos  to  San  Isabel  we  ate  on  the  open  deck,  sat  in  the 
evening  on  the  deck,  and  slept  in  cabins  without  nets 
and  were  not  troubled.  The  boat,  however,  had  been 
thoroughly  renovated  and  cleaned  before  leaving 
Manaos.  At  San  Isabel,  although  the  other  pests  were 
in  full  force,  mosquitoes  were  not  felt,  although  in 
walking  through  the  grass  in  the  evening  a  few  were 
seen  rising,  and  embryos  were  found  in  the  water  col- 
lected in  the  bottom  of  an  old  canoe.  This  is  at  variance 
with  the  ideas  held  and  with  the  reports  of  travellers, 
and  is  to  a  certain  extent  due  to  the  period  of  the  year 
in  which  we  were  in  the  country.  The  relation  of  the 
mosquitoes  to  the  river  travel,  and  to  malaria  will  be 
taken  up  elsewhere. 

The  Smaller  Towns  on  the  Amazon 

High  up  on  the  Amazon  above  the  Rio  Negro  there 
are  a  number  of  small  towns  which  we  did  not  visit  and 
which  are  inferior  in  size  and  importance  to  those  lower 
dow^n.  These  towns,  such  as  Tabatinga,  Teffe,  Fonta- 
boa,  Coary,  are  rarely  visited  by  strangers  and  are 
known  from  the  early  explorers  who  spent  some  time  in 
each  of  them.  They  are  usually  situated  on  high  ground 
on  the  bank  of  the  river  where  there  is  an  entering 
affluent.  They  are  the  headquarters  of  the  trade  of  the 
region  and  as  far  as  can  be  learned  they  present  about 


30  THE  RICE  EXPEDITION  TO  BRAZIL 

the  same  conditions  as  far  as  health  is  concerned  as  the 
lower  towns. 

The  general  impression  given  by  these  Amazonian 
towns  is  that  they  are  comparatively  healthy  and  have 
in  them  the  conditions  which  might  give  a  pleasant  life. 
They  have  malaria  but  this  does  not  seem  to  be  a  grave 
form,  certainly  not  hke  the  type  we  saw  on  the  lower 
Rio  Negro.  All  of  the  accounts  given  of  the  Amazon 
bear  this  out.  The  grave  forms  of  fever  are  found  not 
here  but  high  up  on  the  tributary  rivers.  Of  course  such 
cursory  visits  as  ours  could  determine  very  little  of 
health  conditions;  there  are  no  vital  statistics  of  the 
region,  and  if  there  were  they  would  be  unreliable.  The 
appearance  of  the  people  has  some  value,  and  from  this 
we  should  say  that  the  region  is  fairly  healthy,  and  the 
conditions  for  existence  easy.  Certain  diseases  common 
with  us  seem  to  be  rare.  We  rarely  saw  a  tumor,  or 
any  cases  evidently  tuberculous,  nor  were  there  super- 
ficial evidences  of  uncinariasis  in  high  degree  anaemias. 
Of  the  prevalence  of  insect  plagues  we  could  not  judge 
for  our  stay  was  too  brief,  certainly  we  were  not  troubled 
with  mosquitoes  or  other  insects.  The  shore  conditions 
along  the  Amazon  river  are  not  favorable  for  piums, 
and  several  members  of  the  party  who  made  at  Monte 
Alegre  and  Santarem  long  excursions  into  the  country 
did  not  acquire  micuims,  but  these,  however,  are  pretty 
generally  distributed  throughout  the  valley.  There  is 
almost  an  utter  lack  of  physicians,  in  some  of  the  towns 
there  are  none  and  of  course  none  in  the  country. 

The  Towns  of  the  Lower  Amazon 

Monte  Alegre  (delectable  mountain),  the  name  being 
derived  from  the  nearby  low  mountains  which  are  a 
continuation  from  the  mountains  of  Guiana,  was  the 


MEDICAL  REPORT  31 

first  of  the  Amazonian  towns  visited  after  leaving  Para. 
It  is  situated  not  on  the  Amazon  directly,  but  on  the 
bank  of  a  smaller  river  eight  miles  from  its  mouth.  A 
steep  hillside  three  hundred  feet  in  height,  rising  to  a 
broad  plateau,  divides  the  town  into  an  upper  and  lower 
part.  The  lower  town  lies  along  the  river  and  consists 
of  a  long  street  facing  this  and  several  short  streets  at 
right  angles.  The  upper  town  consists  of  a  large  open 
square  with  the  church  and  a  number  of  houses  on  its 
sides,  all  the  houses  small  and  of  inferior  construc- 
tion. There  are  springs  high  up  on  the  hillside,  the 
water  from  which  is  conducted  into  the  town.  The 
country  back  of  the  town  is  high  campo  and  is  given 
over  to  cattle  raising  and  farming  interests.  There 
'was  the  unusual  spectacle  of  horsemen  riding  along 
the  streets. 

The  day  of  our  arrival  was  a  holiday  and  there  w^ere 
a  large  number  of  people  in  the  town.  Specimens  of 
blood  were  taken  from  twenty  people.  Eighty  per  cent 
of  those  examined  gave  a  history  of  malaria  and  all  but 
two  had  been  well  treated  by  a  pharmacist  with  injec- 
tions of  quinine  hydro  bromate.  Unfortunately  we  did 
not  examine  for  enlarged  spleens,  but  we  did  not  notice 
any  children  with  prominent  abdomens,  so  common  a 
sight  on  the  Rio  Negro,  nor  did  any  of  the  people  com- 
plain of  this  trouble.  The  people  were  healthy  looking 
in  spite  of  the  fact  that  so  many  gave  a  malarial  history; 
for  example,  in  a  group  of  fifteen  who  were  questioned 
but  whose  blood  was  not  examined,  twelve  gave  a  his- 
tory of  malaria  (Fig.  10).  The  pharmacist  said  that 
malaria  was  very  prevalent,  especially  in  late  summer, 
August,  September,  October,  and  November;  there  w^as 
less  in  the  winter  or  wet  season,  although  mosquitoes  are 
worse  at  that  time.    Severe  and  fatal  forms  of  malaria 


32 


THE  RICE  EXPEDITION  TO  BRAZIL 


were  occasionally  met  with  but  quinine  usually  effected 
a  cure.  We  learned  that  diseases  other  than  malaria 
were  rare  and  we  saw  none  save  a  man  with  keratitis, 
probably  due  to  syphilis.  The  infant  mortality  was  said 
to  be  high.    We  found  a  number  of  persons  who  spoke 


Fig.  10.     View  of  inhabitants  of  Monte  Alegre.     The  inn-keeper 
IN  the  foreground,  the  wrestler  in  doorway. 

English  and  who  acted  as  interpreters,  among  them 
a  very  stalwart  Syrian  who  had  come  down  from 
Manaos  for  a  brief  holiday  and  who  said  he  was  the 
first  among  wrestlers  of  the  second  class.  There  is  no 
hospital.  Tertian  parasites  were  found  in  two  of  the 
cases  examined. 

Obidos 

This  is  a  town  situated  on  the  high  bank  of  the  Ama- 
zon about  five  hundred  miles  from  Para ;  the  population 
three  to  five  thousand.  The  situation  is  very  pictures- 
que, the  tile  roofs  of  the  houses  and  the  church  standing 


MEDICAL  REPORT  33 

out  amid  a  forest  of  palms  and  other  trees.  The  narrow- 
est part  of  the  river  is  here,  the  greatest  depth  and  the 
most  rapid  current.  The  yacht  anchored  in  twenty -five 
fathom  of  water,  three  hundred  feet  from  the  bank.  We 
first  called  upon  M.  Paul  Le  Cointe,  a  French  gentleman 
who  had  married  a  Brazilian  wife  and  who  had  large 
plantations  on  the  river.  He  is  a  naturalist,  well  known 
for  his  contributions,  a  collector  of  objects  pertaining 
to  the  anthropology  and  natural  history  of  the  region, 
and  has  received  the  medal  of  the  Legion  of  Honor.  He 
has  a  large  house  and  a  beautiful  garden,  in  which  in 
addition  to  plants  peculiarly  tropical  are  many  roses  and 
our  ordinary  perennials  and  annuals.  All  these  familiar 
flowers  were  inferior  to  the  same  in  our  gardens.  It  was 
Sunday  and  we  probably  saw  most  of  the  population  on 
the  streets,  in  the  cathedral  and  about  the  football 
ground  in  front  of  the  cathedral,  where  a  ball  game  was 
in  progress.  The  people  generally  looked  healthy  and 
well  nourished.  Six  blood  examinations  were  made,  one 
of  them  positive,  the  organisms  young  forms  of  tertian. 

Itacoatiari 

This  town,  the  old  name  Serpa  (Fig.  11),  was  visited 
later  on  the  trip  to  the  Autaz.  It  is  situated  on  high 
ground  on  the  north  bank  of  the  Amazon,  almost  oppo- 
site the  Madeira  river  and  it  was  supposed  that  it  would 
have  a  large  trade  in  connection  with  the  Madeira  and 
Marmore  railroad.  It  was  formerly  a  rival  of  Manaos 
but  has  declined  in  population  and  in  importance.  It  is 
a  small  and  beautiful  town  of  about  two  hundred  houses 
and  back  of  it  is  a  fine  agricultural  country  which  pro- 
duces corn,  cattle,  tobacco,  cacao,  etc.  The  principal 
trade  is  in  Brazil  nuts,  immense  quantities  of  w^hich  were 
in  barges  moored  in  the  river.    We  were  shown  also  the 


34 


THE  RICE  EXPEDITION  TO  BRAZIL 


sapocaia,  a  thin-shelled  delicious  nut  which  rarely  enters 
into  commerce.  There  was  no  physician  in  the  town  but 
from  conversation  with  one  of  the  merchants  who  had 


Fig.  11.     Itacoatiari  from  the  river. 

lived  in  Philadelphia  for  some  time  we  learned  that  the 
place  was  in  point  of  health  similar  to  the  other  towns; 
fairly  healthy,  some  malaria  always  but  more  at  the  end 
of  the  rainy  season.    No  mosquitoes  were  seen. 

Santarem 

Santarem  (Fig.  12),  six  hours  distant  from  Monte 
Alegre,  is  situated  on  the  Amazon  at  the  entrance  of  the 
Tapajos  river.  The  Tapajos  is  a  black  water  river  and 
its  entrance  into  the  Amazon  is  marked  by  the  usual 
sharp  line,  the  admixture  of  waters  taking  place  slowly. 
The  two  streams  seem  to  struggle  at  the  line  of  junction 
and  masses  of  the  two  waters  boiling  up  from  below 
make  mutual  inroads.  The  town  is  divided  into  two 
parts,  one  containing  the  business  houses  and  more  pre- 
tentious dwellings,  and  the  other  chiefly  composed  of 
palm  houses  straggling  up  a  hillside.  There  is  a  cathe- 
dral presided  over  by  a  bishop  whose  house  adjoins. 
On  landing  we  visited  one  of  the  physicians  of  the  town, 
Dr.  Nelto,  whom  we  found  to  be  a  very  courteous  and 


MEDICAL  REPORT 


35 


cultured  Spanish  gentleman.  He  lives  in  a  large  and 
comfortable  house  with  wide  central  hall  and  big  rooms, 
all  paved  with  tile.  In  the  absence  of  an  interpreter 
conversation  was  difficult,  but  we  managed  to  explain 
the  object  of  our  visit  and  to  ask  a  few  questions.  He 
said  there  was  little  sickness  just  then,  the  morbidity 
being  greater  in  the  wet  season  (we  were  told  the  oppo- 
site in  Monte  Alegre)'.  The  commonest  diseases  are 
malaria  and  uncinariasis.  Leprosy  is  prevalent  and 
there  is  a  leper  colony  on  a  nearby  island.    There  is  some 


Fig.  12.     Santarem.    The  cathedral  and  residence  of  bishop 
on  the  right. 

paratyphoid  but  no  typhoid,  as  shown  by  agglutination 
tests  done  in  Para.  We  felt  very  uncertain  about  this  as 
there  is  no  public  laboratory  in  Para  where  such  tests 
could  be  made.  With  the  doctor  we  went  to  see  two  of 
his  patients,  both  with  continued  fever,  listless,  weak, 
presenting  the  appearance  of  typhoid.  There  seems  to 
be  a  curious  custom  of  having  the  patients  brought  in  to 
see  the  doctor  who  remains  in  the  sitting-room  with  the 
family  and  this  seemed  to  entail  much  hardship  on  both 
of  the  patients. 

We  then  called  upon  the  bishop,  an  intelligent  Ger- 
man, who  with  several  Franciscan  fathers  lived  at  a 
house  next  to  the  cathedral.     He  has  lived  in  Brazil 


36  THE  RICE  EXPEDITION  TO  BRAZIL 

twenty  years  and  previously  was  stationed  in  Bahia  and 
Pernambuco.  He  considered  the  country  as  a  whole  very 
healthy  but  thought  that  leprosy  was  on  the  increase. 
The  government  pays  but  little  attention  to  the  colony 
of  lepers  who  fared  better  in  the  days  of  the  empire. 
He  confirmed  the  doctor  in  saying  there  was  more  sick- 
ness in  winter  (the  rainy  season)  than  in  the  summer. 
The  people  congregate  in  the  town  in  the  winter  and  go 
out  to  the  farms  in  the  summer.  The  bishop  makes 
extensive  trips  visiting  the  Indian  missions,  often  travel- 
ling hundreds  of  miles  in  canoes.  He  told  us  that  the 
essentials  for  safety  in  such  travelling  were  a  life  pre- 
server always  worn  in  a  canoe,  for  these  vehicles  lack  in 
stability,  a  hammock  with  mosquito  bar,  and  quinine. 
The  cathedral  contains  a  tablet  placed  there  by  the 
King  of  Bavaria  as  a  thank  offering  for  the  miraculous 
preservation  of  the  life  of  the  botanist  Martins,  who  was 
overturned  in  a  canoe  near  the  town. 

The  population  of  the  town  is  from  five  to  seven 
thousand,  always  greater  in  the  wet  season.  We  exam- 
ined the  blood  of  six  people,  including  the  fever  patients 
of  Dr.  Nelto,  and  all  were  negative  for  malarial  para- 
sites. The  spleens  of  these  persons  were  not  examined, 
but  on  the  return  trip  seven  boys  were  examined  and 
none  of  these  had  a  palpable  spleen. 

The  Cities  of  the  Amazon 

Para  (Fig.  13),  about  one  hundred  thousand  inhabi- 
tants, the  capital  of  the  state  of  Para,  which  comprises 
the  eastern  half  of  the  Amazon  valley,  lies  on  the  Para 
river,  a  great  estuary  which  is  connected  with  the 
Amazon  by  numerous  channels  and  formed  by  the  To- 
cantius  and  a  number  of  smaller  rivers  which  empty 
into  it.    The  city  is  flat,  probably  at  no  place  more  than 


MEDICAL  REPORT 


37 


forty  feet  above  tide  level;  the  newer  part  is  well  laid 
out  in  avenues  with  streets  at  right  angles,  but  the  older 
part  around  the  water  front  is  more  irregular.  Formerly 
yellow  fever  was  endemic  and  caused  yearly  a  great 
mortality,  but  this  has  now  been  done  away  with  by  the 
modern  methods  of  control.  The  streets  generally  are 
clean  and  are  planted  with  mangoes  and  a  very  beautiful 
fig  with  small,  clean,  glistening  leaves,  a  very  much 
better  tree  for  tropical  cities  than  the  more  picturesque 


Fig.  13.     Para.     The  water  front. 

banyan,  which  is  also  a  fig.  Formerly  the  chief  tree  used 
for  shading  the  streets  was  the  mango,  a  beautiful  tree 
giving  dense  shade  but  producing  much  litter,  and  the 
irregularities  of  the  trunk  allow  small  accumulations  of 
rain  water,  in  which  the  yellow  fever  mosquitoes  were 
said  to  breed.  The  mango,  however,  has  the  advantage 
of  giving  an  important  food  supply  by  its  abundant 
fruit.  The  matter  of  trees  in  tropical  cities  is  of  great 
importance,  for  they  add  greatly  to  the  attractiveness  of 
the  city  and  the  comfort  of  the  inhabitants.  The  fig 
used  here  {Ficus  Benjamani)  with  its  symmetrical  round 
crown,  its  fine,  clean,  glistening  foliage,  the  interesting 
aerial  roots  which  form  attachments  with  the  trunk, 


38  THE  RICE  EXPEDITION  TO  BRAZIL 

and  the  fine  color  of  this,  makes  it  the  best  tree  for  street 
planting  which  we  have  seen. 

There  are  many  public  squares  in  the  city,  generally 
well  planted  and  cared  for,  containing  handsome  palms 
and  flowering  shrubs.  There  is  a  small  park  of  about 
thirty  acres,  easily  accessible  by  tram,  and  containing 
numbers  of  fine  forest  trees,  many  of  which  can  be  seen 
in  their  full  proportions  as  much  of  the  lower  forest 
growth  has  been  removed.  Two  miles  from  the  city  is  a 
more  extensive  park  where  the  original  forest  has  been 
left  intact  save  for  the  cutting  necessary  for  the  few 
paths.  There  is  a  museum  founded  by  Goeldi  in  1894 
which  has  a  good  library  and  is  rich  in  objects  represent- 
ing the  anthropology  and  natural  history  of  the  Amazon 
region.  The  garden  contains  an  interesting  collection 
of  palms  and  other  trees  and  a  very  good  collection  of 
the  fauna  of  the  region,  all  well  cared  for.  The  whole  is 
under  the  charge  of  Dr.  Schnetlage,  who  has  herself 
made  a  number  of  explorations  and  important  con- 
tributions to  knowledge. 

The  climate  is  agreeable,  though  warm,  the  ther- 
mometer ranging  between  80°  and  90°,  rarely  exceeding 
these  temperatures.  The  rainfall  is  large,  without  great 
variation  between  the  wet  and  dry  season.  The  morn- 
ings are  generally  warm,  but  hard  showers  in  the  after- 
noon bring  a  grateful  coolness  which  lasts  through  the 
night.  The  temperature  in  the  two  periods  we  were 
there,  December  and  April,  though  warm  was  not  un- 
comfortable except  during  one  morning  when  we  made 
an  excursion  to  the  forest  (91°).  High  temperature  is 
recognized  as  a  constant  condition  and  adjustment  to 
this  is  sought  in  clothing  and  housing.  Underwear  is 
generally  discarded  and  clothing  resolves  itself  into  pan- 
taloons, shirt,  coat,  stockings  and  shoes,  and  frequently 


MEDICAL  REPORT  39' 

one  or  more  of  these  seeming  essentials  are  discarded. 
The  convention  in  regard  to  the  coat  is  firmly  held,  it 
must  be  worn  on  the  street,  and  a  coatless  man  is 
relegated  to  the  last  seats  in  a  tram  car,  among  the 
laborers.  An  adjustment  of  the  body  to  a  constant  high 
temperature  seems  to  take  place  rather  quickly,  after 
which  the  heat  does  not  trouble.  The  brilliancy  of  the 
sunshine,  the  extreme  amount  of  light,  is  at  first  more 
unpleasant  to  bear  than  is  the  heat,  but  here  also 
adaptation  soon  comes. 

Para,  under  the  old  name  of  Belem,  which  there  is 
some  attempt  to  restore,  was  formerly  much  frequented 
by  the  tuberculous,  an  unfortunate  choice,  for  to  a 
climate  most  unsuitable  for  this  disease  were  added 
the  dangers  of  yellow  fever  and  malaria.  The  people, 
as  seen  on  the  streets  and  in  the  shops,  the  soldiery  and 
the  police  struck  us  as  being  undersized.  They  do  not 
look  happy,  there  are  few  smiles  and  little  laughter. 
This,  which  was  very  noticeable  on  our  first  visit,  did 
not  strike  us  on  our  return,  for  we  had  become  accus- 
tomed to  it.  The  Portuguese  sailors  and  laborers  (im- 
migrants) are  large  and  muscular  men,  but  possibly  less 
so  than  the  average  American  laborer.  There  is  no 
evidence  of  extreme  poverty  and  beggars  are  rare.  The 
people  were  said  by  Dr.  Schnetlage  to  be  extremely 
kind  to  one  another.  A  somewhat  limited  experience 
in  the  tropics  seems  to  show,  in  Anglo-Saxon  women,  a 
tendency  to  thinness  in  contrast  to  those  of  their  sisters 
who  have  felt  even  remotely  the  touch  of  the  tar  brush. 
The  population  embraces  many  nationalities  and  there 
are  all  sorts  of  admixtures  with  the  negro. 

Para  was  the  first  city  founded  in  Brazil  and  it  has 
played  an  important  part  in  the  history  of  the  country, 
particularly  in  the  first  half  of  the  last  century,  when 


40 


THE  RICE  EXPEDITION  TO  BRAZIL 


the  monarchy  was  founded  and  the  country  became 
independent.  It  will  further  always  be  known  from  the 
writings  of  the  remarkable  group  of  explorers  who  stud- 
ied the  Amazon  region  about  the  middle  of  the  last  cen- 
tury. Martins,  Bates,  Spruce,  Wallace,  Agassiz,  all  spent 
some  time  here.  When  Bates  was  here  in  1847  the  city 
stood  on  the  edge  of  the  primeval  tropical  forest,  which 
is  now  represented  only  in  the  large  park  at  the  water- 


FiG.  14.     The  public  hospital  of  Para. 

works.  He  lived  at  St.  Nazareth  in  a  small  house  at  the 
edge  of  the  forest  which  has  now  disappeared.  His 
descriptions  of  the  forest  as  he  then  saw  it  apply 
perfectly  to  the  conditions  seen  in  the  large  park. 

Para  has  an  excellent  public  hospital  (Fig.  14),  not 
only  the  best  in  the  Amazon  cities,  but  one  which  will 
bear  comparison  with  municipal  hospitals  anywhere. 
It  is  a  large,  well  constructed  stone  building,  in  the 
eastern  section  of  the  city,  and  with  its  garden  and 
courts  covers  an  entire  city  block.  There  are  twelve 
wards,  each  containing  thirty-five  beds,  giving  accom- 
modations for  at  least  three  hundred  and  fifty  patients. 


MEDICAL  REPORT 


41 


The  wards  are  large  and  airy  and  open  into  a  long  cor- 
ridor by  folding  doors.  It  was  remarkable  to  see  no 
screens  and  yet  an  entire  absence  of  flies  and,  certainly 
during  the  day,  of  mosquitoes.  In  the  courts  between 
the  wards  (Fig.  15)  there  are  well  cared  for  gardens 
with  handsome  palms  and  quantities  of  flowers;  every 
window  looks  upon  a  pleasing  scene.  It  is  under  the 
care   of   a   sisterhood,  is   scrupulously   clean,   and   the 


Fig.  15.     Pubi.ic  hospital.     Coxjrt  between  wards. 

patients  are  well  cared  for.  There  are  good  operating 
rooms.  X-ray  rooms,  and  the  general  equipment  in 
instruments  and  appliances  is  good.  There  is,  however, 
no  pathologist  and  no  system  of  resident  internes,  and 
post  mortem  examinations,  so  important  for  stimulating 
the  scientific  spirit  and  general  morale  of  a  hospital,  are 
not  made.  The  hospital  is  supported  by  the  free  will 
offerings  of  the  people  through  a  hospital  association 
with  initiation  fees  and  yearly  dues,  to  which  every  per- 
son who  can  afford  it  belongs.  We  were  told  that 
membership  in  the  association  confers  a  certain  social 


42 


THE  RICE  EXPEDITION  TO  BRAZIL 


prestige.  Dr.  Utra  Vas,  who  is  the  chief  surgeon  of  the 
hospital,  was  very  kind  and  showed  us  the  cases  in 
the  wards.  The  doctor  was  educated  in  England  and  in 
Germany  and  speaks  both  languages  with  facility.  He 
has  large  offices,  well  fitted  with  modern  appliances  and 
a  number  of  assistants  who  take  care  of  the  laboratory 
examinations  and  do  much  of  the  special  work,  the  whole 
forming  a  well  organized  surgical  clinic  (Fig.  16).     In 


Fig.  16.    Interior  of  ward.     The  beautiful  floor  is  formed  of 

ALTERNATING    BOARDS    OF    ITAUBA    (bLACK)    AND    AMARILLA    (yELLOW) 
WOODS   WHICH   ARE   ALMOST   INDESTRUCTIBLE. 

the  wards  we  saw  a  number  of  types  of  the  Leishmania 
ulcers  which  were  treated  with  hypodermic  injections 
of  antimony,  and  a  number  of  cases  from  the  rivers 
with  the  immense  spleens  with  which  we  had  become 
familiar. 

We  append  what  health  statistics  we  have  been  able 
to  acquire,  together  with  other  data.  The  records  of 
later  years  are  not  accessible.  The  estimate  of  popu- 
lation is  certainly  erroneous,  for  the  cities  here  see  their 
population  under  a  magnifying  glass,  a  fault  to  which 
those  of  other  countries  are  not  immune.    The  statistics 


MEDICAL  REPORT  43 

are  probably  not  very  reliable  as  is  shown  in  the  varia- 
tions in  the  number  of  deaths  from  certain  common 
diseases.  The  very  low  incidence  of  tumors  is  in  accord 
with  our  observations  everywhere  we  went.  The  very 
striking  decline  in  mortality  from  yellow  fever  is  the 
result  of  preventive  measures  instituted  in  1911.  The 
average  yearly  temperature  and  rainfall  is  given  for  but 
tw^o  years. 

Population  Average  Rainfall 

Year  (estimated)  temperature  in  inches 

1907 185,000 

1908 185,000 

1909 185,000 

1910 190,000     80.9°  F.      107.21 

1911 1 190,000     80.4°  F.      100.4 

1912  2 200,000 

1  All  data  for  the  years  1912,  1913,  and  1914  were  obtained  from  the  Office  International  d'Ey- 
giene  Publigue  annual  reports  for  those  years.  All  other  data,  with  the  exception  of  the  population 
estimates  for  the  years  1907,  1908,  and  1909  obtained  from  the  consular  reports,  were  taken  from  the 
Annuario  de  Estatisttca  Demographo-Sanitaria  for  the  years  1910  and  1911.  These  two  reports  were 
published  in  1913  and  1914  respectively. 

2  The  1911  report  of  mortality  statistics  combined  certain  causes  as  indicated  in  the  chart  on 
pp.  44  and  45. 


44 


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46  THE  RICE  EXPEDITION  TO  BRAZIL 

Manaos 

Manaos,  known  formerly  as  Barra,  has  a  fine  situa- 
tion on  high  ground  on  the  north  bank  of  the  Rio  Negro, 
nine  miles  above  the  entrance  of  this  into  the  Amazon. 
The  Rio  Negro  is  a  clear  black  water  river  and  there  is  a 
sharp  line  marking  the  junction  of  its  waters  with  the 
turbid  yellow  stream  of  the  Amazon,  which  can  be  fol- 
lowed for  many  miles.  The  city  is  the  centre  of  the 
rubber  industry  of  Brazil  and  during  the  period  of  high 
prices  for  rubber  which  was  terminated  by  the  present 
war,  was  very  prosperous.  Most  of  the  steamers  which 
serve  the  river  trafiic  of  the  central  and  most  of  the 
western  part  of  the  Amazon  valley  make  this  their  home 
port.  The  city  is  not  lacking  in  picturesqueness ;  there 
are  handsome  wide  avenues  well  planted  with  fig  and 
mango  trees,  the  public  squares  are  numerous,  beautiful 
and  well  cared  for,  but  there  is  no  public  park.  The 
theatre,  situated  on  the  highest  land  in  the  city  with  a 
dominating  dome  of  blue  glazed  tile  forms  the  most  con- 
spicuous object  and  focuses  the  civic  pride.  The  build- 
ing is  poorly  constructed  and  in  bad  taste.  There  are 
some  very  good  public  buildings  and  the  foundations  of 
others,  the  funds  appropriated  for  their  construction 
having  disappeared  before  the  buildings  could  get 
higher.  There  is  a  dignified  old  cathedral  in  the  middle 
of  a  fine  square,  but  the  whole  city  is  very  different  from 
the  quiet  and  dignity  of  Para  and  gives  one  the  impres- 
sion of  a  rapidly  developed  frontier  town  seen  in  its  most 
unfortunate  time,  that  is,  at  the  decline  of  a  period  of 
great  expansion.  The  rise  of  the  city  really  dates  from 
1807  when  the  capital  of  the  province  was  transferred 
from  Barcellos  here.  In  1829  when  Mar  was  here  he  esti- 
mated the  population  at  three  thousand.     It  increased 


MEDICAL  REPORT  47 

rapidly  with  the  rise  of  the  rubber  industry  which  reached 
its  acme  in  1913-14.  Great  wealth  flowed  into  the  city, 
and  with  this  came  adventurers  from  the  entire  world 
to  share  in  the  prosperity.  Even  now  there  is  probably 
no  city  of  its  size  with  such  a  cosmopolitan  population. 
The  hospital  is  an  old  structure  totally  inadequate 
and  dirty.     Mar  speaks  of  the  hospital  as  a  spacious 


Fig.  17.     Court  in  the  Manaos  hospital. 

structure  which  had  just  been  completed,  and  no  doubt 
it  then  and  for  a  considerable  period  fully  sufficed  for 
the  needs  of  the  city.  It  is  rather  curious  that  at  a 
time  when  there  was  much  yellow  fever  in  the  place 
some  of  the  money  expended  in  the  costly  and  showy 
theatre  should  not  have  been  turned  to  giving  better 
conditions  for  the  sick  (Fig.  17).  The  only  circum- 
stance favorable  to  the  hospital  lies  in  the  statement  of 
the  physicians  that  it  was  formerly  much  worse  than 
at  present.  In  addition  to  this  public  hospital  there 
is  a  smaller  hospital,  called  the  Portuguese,  which  is 


48 


THE  RICE  EXPEDITION  TO  BRAZIL 


entirely  for  pay  patients,  is  well  provided  and  seemingly 
well  managed.  It  is  conspicuous  from  the  harbor, 
standing  on  an  eminence  and  still  shows  the  ruin  pro- 
duced four  years  ago  when  it  was  subjected  to  a  bom- 
bardment from  a  government  man-of-war  in  the  harbor. 
This  was  on  the  occasion  of  a  gubernatorial  election 
when  the  local  authorities  were  not  in  full  sympathy 
with    the    government.      A    small    military    hospital 


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Fig.  18.     Manaos  military  hospital. 

(Fig.  18)  stands  just  outside  of  the  city.  On  either  side 
of  the  city  there  are  igarapes  which  extend  a  consider- 
able distance  inland,  and  in  the  expansion  which  the 
city  underwent  during  the  period  of  prosperity  streets 
were  run  across  these  ravines  without  adequate  provi- 
sion for  drainage,  leading  to  the  formation  of  large  pools 
which  served  for  mosquito  breeding.  The  banks  were 
endemic  foci  for  yellow  fever. 

The  city  offers  an  interesting  example  of  what  may  be 
accomplished  by  one  man  with  the  great  possessions  of 
knowledge,  intelligence,  public  spirit,  and  energy.  This 
rare  combination  has  enabled  Dr.  H.  Wolferston  Thomas 


MEDICAL  REPORT  49 

to  accomplish  the  wonderful  work  he  has  done  here. 
Thoroughly  trained  in  the  Liverpool  School  of  Tropi- 
cal Medicine,  and  with  an  accomplishment  of  valuable 
researches  in  this  field,  his  work  has  been  accurate, 
scientific,  controlled  by  laboratory  and  experimental 
methods,  and  he  is  untiring.  He  is  physician,  coun- 
selor, and  friend  to  the  English  colony,  extends  his 
influence  in  all  directions  in  which  he  can  be  of  service 
and  he  has  won  the  respect  and  admiration  of  the  local 
physicians  and  the  people.  Such  an  accomplishment 
by  a  man  working  alone  without  the  sympathy  and 
encouragement  which  come  from  association  with  men 
engaged  in  similar  work  is  remarkable.  He  lives  in  a 
house  which  combines  in  it  a  small  hospital.  During  the 
prevalence  of  yellow  fever  he  was  very  successful  in  its 
treatment,  the  essential  principle  of  which  was  the 
ingestion  of  vast  quantities  of  carbonated  water.  The 
measures  for  the  eradication  of  the  disease  undertaken 
in  1913  were  under  his  direction. 

There  seems  to  be  a  good  deal  of  leprosy.  Early 
anesthetic  forms  of  this  were  seen  in  the  general  hospital 
and  there  is  a  small  leper  colony  a  few  miles  from  the 
city  where  twenty-four  cases  are  segregated.  As  this 
seemed  a  small  number  the  question  was  asked  whether 
these  were  all  the  cases  in  the  district,  and  the  reply  was 
"  Why  no,  there  are  possibly  one  thousand."  The  cases 
seen  were  advanced  tubercular  and  mutilating  forms 
and  probably  only  the  most  advanced  and  evident  cases 
are  sent  here  to  be  cared  for.  The  colony  is  well  placed 
on  high  land  on  the  bank  of  the  river,  there  are  abundant 
fruit  trees  and  vegetable  gardens,  the  small  necessary 
care  of  which  is  given  by  the  lepers,  the  river  furnishes 
fish  and  the  cost  of  the  asylum  is  small.  The  buildings, 
though  adequate,   are  mere  shacks.     One  man,   who 


50 


THE  RICE  EXPEDITION  TO  BRAZIL 


seemed  to  be  of  a  somewhat  higher  social  status  than 
the  others,  lived  alone,  had  his  own  garden,  fruit  trees, 
and  poultry,  which  he  tended,  and  the  palm  house 
(Fig.  19)  which  he  had  built  himself  was  well  constructed 
and  clean.  He  has  directed  that  when  he  is  dead  the 
house  shall  be  burned  with  his  body. 

The  city  has  an  excellent  and  adequate  water  supply. 
The  abattoir  system  and  the  distribution  of  meat  is 


Fig.  19.     Leper  and  house  which  he  has  built. 

interesting  and  the  same  in  the  three  Amazonian  cities 
Para,  Manaos,  and  Iquitos.  Cattle  are  very  abun- 
dant and  cheap.  They  are  brought  to  market  directly 
from  the  pastures,  and  when  alive  seem  to  be  in  good 
condition,  but  when  slaughtered  the  meat  as  seen  in  the 
markets  has  not  an  appetizing  appearance.  The  blood 
seems  to  undergo  rapid  hemolysis  and  all  the  flesh  has 
the  diffuse  hemoglobin  stain.  The  cattle  are  killed  in 
the  abattoirs  after  four  o'clock  in  the  afternoon  and  the 
meat  distributed  to  the  markets  and  provision  stores 


MEDICAL  REPORT  51 

during  the  night,  being  carried  either  by  bullock  carts 
or  as  in  Para  by  the  tram  cars.  No  fresh  meat  can  be 
sold  after  11  a.m.,  and  there  is  a  rapid  fall  in  price  as 
this  hour  is  approached.  It  might  seem  that  an  improve- 
ment could  be  effected  by  keeping  the  meat  in  cold 
storage  for  a  couple  of  days  before  consumption  as  all 
of  these  cities  have  local  ice  plants. 

Milk,  both  in  the  cities  and  in  the  country,  plays  but 
a  small  part  in  the  food  of  the  people.  It  is  all  boiled 
before  using  and  is  not  a  pleasant  drink.  In  the  Autaz 
region,  where  the  raising  of  cattle  is  the  main  industry, 
there  was  considerable  consumption  of  milk  in  the  form 
of  menhada,  or  clotted  milk,  which  was  delicious.  Both 
in  Manaos  and  in  Iquitos  we  saw  goats  driven  along  the 
streets  and  milked  at  the  house  doors,  the  product  being 
used  for  children.  In  Itacoatiari  we  saw  early  in  the 
morning  the  conventional  milk  cart  dispensing  milk 
from  a  large  tin  receptacle. 


52 


THE  RICE  EXPEDITION  TO  BRAZIL 


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MEDICAL  REPORT 


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54  THE  RICE  EXPEDITION  TO  BRAZIL 

Death  Rate 

Population  Death  rate 

Year  (estimated)  Deaths  per  1000 

1907 50,000  1438  28.7 

1908 50,000  1764  38.5 

1909 50,000  1638  32.7 

1910 60,000  2196  36.6 

1911 60,000  2333  39.0 

1912 60,000  1921  32.0 

1913 70,000  (.?)  1687  24.1  (?) 

1914 70,000  (?)  1305  18.6  (?) 

1915 70,000  (?)  1197  17.1  (?) 

1916 70,000  (?)  1165  16.6  (?) 

Here  it  seems  possible  that  the  very  low  incidence  of 
cancer  may  be  partly  explained  by  cases  wrongly  in- 
cluded under  "  Diseases  of  the  Digestive  System  "  and 
possiblj^  cirrhosis  of  the  liver  also  falls  under  this  cate- 
gory. The  apparent  fall  in  death  rate  since  1913  is 
readily  explained.  It  was  influenced  somewhat  by  the 
fall  in  deaths  from  yellow  fever,  but  the  great  factor  has 
been  the  decline  in  population.  That  this  has  dimin- 
ished in  the  last  four  years  thirty  to  forty  per  cent  is  a 
matter  of  common  knowledge,  the  fall  being  coincident 
with  the  decline  in  importance  of  the  rubber  industry. 
Cutting  down  the  given  estimate  of  population  one  half 
would  give  what  is  probably  nearly  the  correct  figure  of 
33.3  instead  of  16.6. 

The  rainfall  as  given  is  somewhat  less  than  that  of 
Para,  and  the  temperature  is  about  the  same  as  Para. 


Iquitos 

Iquitos  is  the  third  in  size  of  the  Amazon  cities  and  is 
situated  on  the  Amazon  in  Peru  two  hundred  miles 
from  the  Brazilian  border  and  twenty -three  hundred 
miles  from  the  mouth  of  the  river.  It  has  only  recently 
attained  any  importance.  Mar,  who  crossed  the  Andes 
from  Truxillo  in  1829,  and  came  down  the  river,  speaks 


MEDICAL  REPORT  55 

of  it  as  a  pueblo  not  surpassing  in  size  and  number  of 
inhabitants  those  he  had  passed  through  in  the  moun- 
tains. Herndon,  who  passed  through  it  in  1853,  speaks  of 
it  as  composed  of  about  two  hundred  and  fifty  fishermen 
and  inferior  in  importance  to  most  of  the  Brazihan  towns 
on  the  river.  The  city  hes  on  a  high  bank  about  eighty 
feet  above  the  level  of  the  river  at  the  time  we  were 
there,  December  29  to  January  3.  It  is  a  centre  for  the 
collection  and  export  of  rubber  and  since  the  decline  in 
price  of  that  commodity  the  population  has  decreased 
from  18,000  to  12,000.  The  river  shore  forms  the  most 
interesting  and  picturesque  part  of  the  city.  Boats  of 
all  sorts  lie  moored  to  the  bank  and  quite  a  population 
dwells  upon  them  and  may  be  seen  in  the  daily  w^ork  of 
bathing,  washing  clothes,  and  cooking.  Among  these 
boats  are  large  rafts  which  have  come  down  from  the 
smaller  rivers,  making  journeys  often  of  several  hundred 
miles.  On  the  raft  is  a  thatched  house  and  accommoda- 
tions for  cattle  and  poultry,  which  are  carried  for  food  on 
the  way  or  disposed  of  in  the  city.  Both  cargo  and  raft 
are  sold,  the  latter  for  firewood,  and  the  return  journey 
is  made  in  a  steamer  or  in  a  canoe  which  is  towed  down. 
The  bank  is  grown  up  with  patches  of  magnificent  calla- 
diums,  the  leaves  often  four  feet  long  and  two  broad, 
cannas  and  many  flowering  plants.  The  houses  in 
places  straggle  down  the  bank,  assuming  picturesque 
but  apparently  unstable  attitudes.  The  streets  are 
either  very  badly  paved  or  not  at  all,  and  the  drainage 
is  conducted  in  side  ditches  with  pools  at  intervals. 
There  is  no  general  water  supply,  water  being  provided 
by  wells,  cisterns,  and  natural  springs  in  or  near  the 
city,  or  pumped  up  from  the  river.  There  is  but  one 
very  badly  kept  public  square,  with  a  few  almond  trees 
which  with  their  pyramidal  shape  and  tiers  of  horizontal 


56 


THE  RICE  EXPEDITION  TO  BRAZIL 


branches  are  always  pleasing,  but  here  more  or  less 
broken  and  unkempt.  There  are  no  tramways  or  pleas- 
ure vehicles;  joy  riding  being  served  only  by  a  narrow 
gauge  railroad  which  though  ordinarily  used  for  freight 
only,  on  holidays  runs,  at  long  intervals,  a  train  of  tiny 
passenger  cars  a  short  distance  into  the  country.  The 
people  as  a  whole  look  fairly  well  and  have  more  pleas- 
ing faces  than  have  the  Brazilians.  Many  more  Indians 
are  seen,  fewer  negroes  than  lower  down,  and  the  admix- 
ture is  rather  with  the  Indian  than  with  the  negro. 


Fig.  20.     Military  hospital  at  Iquitos. 

There  is  a  hospital  of  forty  beds  situated  about  two 
miles  from  the  centre  of  the  city  which  though  under  the 
care  of  the  army  also  serves  as  a  municipal  hospital 
(Fig.  20).  There  is  a  male  and  female  ward  and  between 
them  a  small  pavilion  for  administration.  All  parts 
of  the  hospital  were  clean  and  the  patients  seemed  well 
cared  for.  The  wards  contained  numerous  cases  of 
ulcers  which  were  diagnosed  as  Leishmania.  One  of 
these  was  owned  by  an  Irishman,  fifty-seven  years  old, 
who  had  come  from  the  Cordilleras,  and  had  been  four- 
teen months  in  the  hospital.  The  physician  in  charge, 
Dr.  Mantero,  was  very  kind  in  showing  us  the  wards 
and  giving  information.  We  used  as  interpreter  one  of 
the  ubiquitous  Barbados  negroes.     Dr.  Mantero  said 


MEDICAL  REPORT 


57 


malaria  was  not  common  in  Iquitos  but  there  was  much 
in  the  surrounding  country.    Occasional  cases  of  dysen- 
tery, both  the  amoebic  and  bacillary  type,  came  to  the 
hospital  and  this  disease  was  more  common  on  the  Napo 
river.    Tuberculosis  was  fairly  common,  and  hookworm 
the  great  scourge  affecting  eighty  per  cent  of  the  popu- 
lation;  twenty  per  cent  of  the  cases  were  of  the  grave 
form  of  anaemia  produced  by  this.    Tropical  ulcers  were 
common   and  did  well  under 
local  antiseptic  treatment ;  the 
intravenous  injections  of  anti- 
mony of  which  we  had  heard 
so  much  in  Para  and  Manaos 
were  not  used.      It  was   also 
very  evident  that  under  the 
name  of  tropical  ulcer  all  sorts 
of  conditions,  both  the  ordi- 
nary varicose  ulcer  and   skin 
carcinoma,  were  included.    On 
the  way  from  the  hospital  we 
crossed  a  ravine  where  there 
are  several  springs,  the  water 
of  which  is  used  for  washing, 
and  forms  a  large  part  of  the  regular  water  supply  of 
the  city,  into  which  it  is  carried  in  large  jars.    The 
washing  was  being  done  in  pools  below  the  springs. 
There  were  many  children  playing  in  the  vicinity  and 
a  number  of  houses  were  above  the  springs  which  were 
low,  the  surface  water  draining  into  them.    All  of  the 
children  seen  here  were  anaemic  and  evidently  infected 
with  hookworm.     Dr.  Mantero  thought  that  the  prin- 
cipal mode  of  extension  of  the  hookworm  infection  was 
by  drinking  water  contaminated  with  the  embryos  of 
the  hookworm. 


Fig.  21. 


Tubercular  leprosy. 
Iquitos. 


58  THE  RICE  EXPEDITION  TO  BRAZIL 

In  the  leper  hospital,  which  is  on  the  outskirts  of  the 
city,  there  were  eight  cases,  of  well  marked  and  advanced 
tubercular  leprosy  (Fig.  21). 

The  appended  health  report  of  the  city  for  1916  is 
interesting  but  we  should  not  care  to  say  that  it  is 
reliable : 

Health  Report  of  the  City  of  Iquitos,  Peru 

1916 

Deaths  in  1916 285 

Births  in  1916 976 

Causes  of  Death 

*Not  specified , 130 

Tuberculosis 30 

Pulmonary 11 

Generalized 10 

Abdominal 1 

Larynx 2 

Pott's  disease 2 

Other  organs 4 

Anaemia 7 


1  f\ 

Intestinal  parasites 9  / 

(Both  probably  refer  to  ankylostomiasis) 

Acute  intestinal  diseases 20 

Diarrhea:  children  less  than  2  years 9 

Diarrhea :  children  more  than  2  years 5 

Dysentery 6 

Malaria 11 

Measles  ("  serampion  ") 10 

Acute  respiratory  infections 14 

Broncho-pneumonia 10 

Lobar  pneumonia 1 

Bronchitis 1 

Grippe 1 

Gangrene  of  Iimg 1 

Syphilis..  . 2 

Aneurysm 3 

General  paresis 1 

Cancer 3 

Female  genital  organs 2 

Other  organs 1 

Tetanus 4 

Cirrhosis 3 


MEDICAL  REPORT  59 

Accidents  of  pregnancy 1 

Puerperal  septicaemia 2 

Congenital  debility 4 

Still  born 2 

Suicides 5 

Poison 1 

Fire-arms 4 

Accidental  drowning 4 

Accidental  burning 1 

Yellow  fever 1 

Rheumatism 1 

Asthma 1 

Chorea 1 

In  looking  over  this  report,  which  on  its  face  is  obvi- 
ously imperfect,  the  first  item  showing  the  great  excess 
of  births  over  deaths  is  striking,  when  it  is  considered 
that  the  city  has  a  declining  population.  The  probable 
explanation  is  that  deaths,  particularly  those  of  children, 
are  not  reported,  and  some  confirmation  is  given  to  this 
by  the  small  number  of  deaths  due  to  infantile  diseases. 
Another  striking  feature  in  the  report  is  that  not  a 
single  death  is  reported  as  due  to  cardiac  and  renal  dis- 
ease. In  the  non-specified  deaths  Dr.  Ferradas,  the  port 
physician,  and  a  man  of  intelligence,  thought  that  fifty 
per  cent  of  these  were  due  to  ankylostomiasis,  which  if 
true  would  make  this  the  most  common  cause  of  death, 
and  it  is  not  improbable  that  some  cardiac  and  renal 
cases  were  included  under  this  category.  Still  we  saw 
no  such  cases  in  the  hospital  and  the  physicians  said 
they  were  very  rare.  We  thought  that  there  might  be 
some  relation  between  this  and  longevity  and  en- 
deavored to  ascertain  something  regarding  the  age  at 
death  by  visiting  the  cemetery  and  getting  the  recorded 
ages  from  the  stones,  but  the  cemetery  though  well 
kept  and  interesting  in  the  varieties  of  trees  which  had 
been  planted,  did  not  give  such  information.  In  most 
cases  age  was  not  given  and  the  average  of  the  sixty 


60  THE  RICE  EXPEDITION  TO  BRAZIL 

ages  which  we  found  was  25.73  which  if  of  any  value  did 
not  bear  out  our  hypothesis  that  Hfe  in  Iquitos  was  of 
short  duration.  Of  the  sixty  cases  eight  were  more  than 
sixty  years  and  there  was  one  of  eighty  and  one  of 
ninety-two.  Another  interesting  feature  in  the  report 
is  that  but  three  deaths  from  cancer  are  recorded.  While 
the  recorded  death  causes  are  usually  those  of  obvious 
diseases,  still  cancer  of  the  breast  and  epidermoid  can- 
cers, superficial  tumors,  etc.,  are  sufficiently  obvious. 
Here  as  elsewhere  in  the  Amazon  valley  tumors  of  all 
sorts,  both  benign  and  malignant,  appear  to  be  relatively 
rare.  We  were  told  that  malaria  was  rare  and  in  the 
report  but  eleven  deaths  are  set  down  as  caused  by  it, 
and  while  in  the  city  we  saw  very  few  mosquitoes.  Why 
malaria  is  not  common  here  is  one  of  the  many  puzzling 
features  of  this  disease  we  encountered.  More  favorable 
conditions  for  mosquito  propagation  could  not  be  con- 
trived, and  infected  individuals  are  constantly  coming 
here  from  the  rivers,  both  above  and  below.  In  death 
reports  the  tendency  would  be  to  attribute  more  rather 
than  less  cases  to  this  cause. 

Such  a  health  report  as  this  with  all-its  obvious  imper- 
fections is  better  than  none  at  all,  for  it  represents  a 
desire  to  do  something,  to  make  some  contribution  to 
knowledge  and  from  such  beginnings  more  perfect  work 
will  proceed. 

Conditions  on  the  Rio  Negro 

The  Rio  Negro,  one  of  the  main  tributaries  of  the 
Amazon,  carries  into  this  the  drainage  of  an  enormous 
area  provided  with  a  great  rainfall.  This  area  com- 
prises the  northern  Amazonas  bordering  on  British 
Guiana,  Venezuela,  and  Colombia,  as  well  as  nearly  the 
entire  western  watershed  of  Colombia.     It  receives  a 


MEDICAL  REPORT 


61 


number  of  rivers,  the  largest  of  which  are  the  Rio 
Branco,  the  Uaupes,  and  the  Guainia.  The  lower  four 
hundred  miles  of  the  river  has  much  the  character  of  a 
lake,  the  fall  is  very  slight,  the  river  is  broad  and  there 
are  great  numbers  of  islands.  Most  of  these  islands  are 
formed  of  (Fig.  22)  igapo,  that  is,  land  ordinarily  a  few 
feet  only  above  the  surface  and  completely  submerged 
during  high  water.     The  true  banks  of  the  river  are 


Fig.  22.    The  lower  Rio  Negro.     Clusters  of  javary  palms. 

formed  of  terra  firme,  but  igapo  and  varzea  extend  to  a 
considerable  distance  along  the  smaller  entering  rivers. 
There  is  a  great  rise  of  the  river  during  the  wet  season, 
more  pronounced  in  the  lower  than  in  the  upper  part. 
San  Isabel,  five  hundred  miles  from  Manaos,  is  at  the 
head  of  steam  navigation  and  the  river  commencing 
some  eighty  miles  below  this  changes  its  character,  is  no 
longer  so  wide,  the  islands  are  less  numerous,  the  cur- 
rent more  rapid,  and  the  banks  composed  of  granite. 
Many  of  the  islands  have  a  granite  foundation  and  single 
projecting  granite  rocks   are  seen    (Fig.   23).     Above 


62 


THE  RICE  EXPEDITION  TO  BRAZIL 


San  Isabel  all  these  conditions  are  more  pronounced  and 
the  river  has  the  character  of  one  coming  from  a  high 
granite  country.  There  are  numerous  and  extensive 
sand  bars  due  to  the  disintegration  of  the  granite  above 
which  seems  to  be  proceeding  rapidly.  The  name  of  the 
river  is  appropriate  to  the  color  of  the  water  which 
though  perfectly  clear,  is  a  pale  amber  as  seen  in  a 
glass,  and  the  mass  of  water  is  jet  black.  At  the  time  we 
were  on  the  river,  January  to  April,  there  was  little 


Fig.  23.     The  Rio  Negro.     Granite  formation. 

wind,  an  occasional  squall  or  rainstorm,  but  usually  the 
river  had  a  glassy  surface  giving  a  perfect  mirror.  The 
ever  present  clouds  of  the  day  and  the  starlit  sky  at 
night  reflected  from  the  black  surface  were  of  wonderful 
beauty.  The  rainy  season,  with  its  period  of  high  water, 
is  from  March  to  June,  but  there  is  usually  a  temporary 
rise  in  December.  The  rise  is  very  great,  the  entire 
lower  part  of  the  river  and  the  islands  being  flooded. 
The  entire  country  on  both  sides  of  the  river  is  heavily 
forested,  there  being  merely  small  clearings  for  pastures 
about  the  villages  and  the  sitios  where  the  large  rubber 
merchants  live. 

The  population  along  the  river  is  extremely  scarce. 
Senhor  Netto,  an  intelligent  gentleman,  the  governor  of 


MEDICAL  REPORT  63 

the  district  of  Barcellos,  estimates  the  population  from 
Manaos  to  the  Venezuelan  border,  a  distance  of  seven 
hundred  miles,  at  not  more  than  five  thousand.  There 
is  no  census  and  this  estimate  is  based  on  the  amount  of 
rubber  which  the  country  produces.  The  population  is 
along  the  rivers,  the  great  stretches  of  forest  between 
being  uninhabited,  save  by  the  few  wandering,  forest 
Indians.  The  country  has  also  never  been  explored, 
the  heights,  the  character,  and  the  relations  of  the 
several  mountain  ranges  have  never  been  determined. 

There  seems  little  doubt  that  the  region  was  formerly 
more  thickly  settled  than  at  present,  as  shown  by  the 
ruined  churches  in  the  villages  and  by  the  traditions  of 
population.  Before  the  days  of  rubber  production  it 
was  an  agricultural  region,  quantities  of  coffee,  corn, 
cacao,  rice,  vanilla,  anatto,  and  indigo  being  produced. 
Senhor  Netto  attributes  the  decline  in  population  to 
several  factors,  such  as  the  introduction  of  disease  by 
the  traders,  the  development  of  the  rubber  industry 
which  caused  the  people  to  neglect  agriculture,  and  with 
all  this  the  extension  of  alcoholism.  The  climate  is 
good,  the  nights  cool,  the  insect  pests,  save  in  certain 
places,  are  not  very  bad,  and  the  soil  is  fertile. 

The  Lower  River 

From  the  view  point  of  disease  there  is  a  sharp  separa- 
tion between  the  lower  and  upper  river  at  San  Isabel,  the 
head  of  steam  navigation.  From  Manaos  to  San  Isabel 
and  on  the  return  we  made  numerous  stops,  sometimes 
for  a  few  hours  only,  at  others  for  several  days,  and 
there  was  opportunity  for  study  of  the  people.  There 
are  many  Indians  and  a  large  admixture  of  Indian 
blood,  comparatively  few  negroes  and  mulattoes.  The 
pure  whites   are   of  various   nationalities,   but   chiefly 


64  THE  RICE  EXPEDITION  TO  BRAZIL 

Portuguese.  The  people  seen  presented  the  indications 
of  ill  health;  the  nutrition  was  poor,  there  was  evident 
anaemia  and  lack  of  energy. 

Malaria  in  the  Cities 

In  Para,  Manaos,  and  Iquitos  there  are  doctors, 
hospitals,  and  more  or  less  efficient  health  departments. 
Hospital  and  city  officials  extended  us  every  courtesy 
making  it  possible  to  collect  considerable  data  regarding 
malaria  and  other  endemic  tropical  diseases  during  our 
brief  visits.  Annual  health  reports  are  published  in  all 
three  cities,  and  in  Manaos  there  are  monthly  reports 
extending  back  for  a  period  of  ten  years. 

According  to  these  reports  malaria  is  not  only  the 
commonest  disease  of  the  country,  but  is  the  direct 
cause  of  much  the  largest  number  of  deaths.  The  figures 
are  quite  astounding.  For  example,  in  Manaos,  out  of 
a  total  of  15,500  deaths  in  the  last  ten  years,  4250,  or 
28  per  cent  are  attributed  to  malaria.  Pulmonary 
tuberculosis,  the  next  most  common  cause,  was  respon- 
sible for  1136  deaths,  or  7  per  cent  of  the  total.  It  may 
be  explained  that  the  tuberculosis  rate  is  almost  as  high 
as  in  New  York,  where  this  disease  stands  first  or  second 
among  the  causes  of  death.  According  to  these  statis- 
tics then,  malaria  causes  four  times  as  many  deaths  as 
any  other  single  disease,  a  number  relatively  five  times 
as  great  as  that  of  any  one  disease  in  New  York.  The 
death  rate  in  Manaos  from  all  causes,  cannot  be  accu- 
rately stated  since  the  population  has  varied  so  much  in 
the  last  ten  years.  It  is  probably  high,  that  is,  35  per 
1000  or  more.    That  of  Para  is  somewhat  lower. 

Are  these  figures  regarding  the  mortality  from  malaria 
reasonably  accurate  "^  Our  investigations,  though  brief 
and  incomplete,  would  indicate  that  they  are  not  and 


MEDICAL  REPORT  65 

we  are  inclined  to  think  that  malaria  does  not  cause  half 
as  many  deaths  as  are  attributed  to  it.  In  the  first 
place,  diagnosis  is  practically  never  confirmed  by 
microscopic  examination  of  the  blood.  In  the  eight 
hospitals  visited,  we  saw  only  a  single  microscope.  This 
was  in  a  small  sanitarium  in  Manaos,  owned  by  an  Eng- 
lish doctor  whose  practice  is  limited  to  the  English 
colony.  Secondly,  we  got  the  impression  that,  as  a 
general  rule,  correct  diagnoses  were  made  only  on  cases 
where  the  nature  of  the  disease  was  obvious,  such  as 
leprosy  or  dysentery,  and  where  there  was  doubt,  ma- 
laria was  the  diagnosis  most  often  set  down.  It  is  the 
scrap  pile,  as  it  were.  Thirdly,  during  our  three  stops 
at  Manaos,  where  we  were  altogether  nearly  three 
weeks,  we  made  a  number  of  visits  to  the  300-bed  muni- 
cipal hospital,  but  we  never  saw  a  single  case  of  severe 
or  fatal  malaria.  One  case  diagnosed  as  such  was  autop- 
sied  by  us  and  found  to  be  pneumococcus  meningitis. 

We  did  see,  however,  any  number  of  people  in  the 
hospital  with  enlarged,  hard  spleens,  who  gave  a  history 
of  fever.  Most  of  these  cases  had  been  admitted  for 
other  troubles,  such  as  dysentery  and  tropical  ulcer. 
In  one  ward,  containing  twenty  ulcer  cases,  there  were 
ten  with  easily  palpable  spleens.  There  can  be  little 
doubt  that  malaria  is  very  prevalent  in  the  cities  and 
towns,  as  well  as  in  the  country,  but  our  observations 
would  indicate  that  the  number  of  deaths  directly  attrib- 
utable to  it  is  much  lower  than  the  statistics  show. 

In  Monte  Alegre,  Santarem,  and  Obidos,  towns  on  the 
lower  Amazon,  conditions  as  regards  malaria  are  about 
the  same  as  in  Para  and  Manaos.  At  least  one  doctor 
or  pharmacist  was  found  in  each  place.  The  doctors  and 
others  with  whom  we  talked  told  us  that  chills  and 
fever  were  common  toward  the  end  of  the  rainy  season 


66  THE  RICE  EXPEDITION  TO  BRAZIL 

especially,  but  that  the  infection  responded  readily  to 
quinine,  which  was  often  administered  subcutaneously. 
The  people  looked  healthy  and  our  blood  specimens  were 
negative  except  in  three  cases.  We  saw  no  big  abdo- 
mens or  enlarged  spleens  such  as  were  a  common  sight 
on  the  Rio  Negro.  We  saw  at  Santarem  three  cases  of 
fever,  which  the  attending  doctor  diagnosed  as  malaria. 
The  patients  were  being  treated  with  quinine  without 
effect,  and  the  cases  looked  to  us  like  typical  typhoid 
fever.  The  doctor,  however,  insisted  that  typhoid  fever 
did  not  exist  in  that  section. 

Malaria  on  the  Rio  Negro 

Our  stay  of  several  months  on  the  Rio  Negro  afforded 
a  better  opportiuiity  for  the  study  of  medical  conditions 
than  was  possible  in  the  cities,  where  our  visits  lasted 
only  a  week  or  two  at  the  most.  There  are  no  doctors  on 
the  river.  In  fact  the  entire  stretch  of  country  between 
Manaos  and  Bogota,  a  distance  of  more  than  a  thousand 
miles,  is  without  medical  aid  of  any  kind.  Medicines, 
except  the  herb  and  plant  extracts  of  the  Indians,  are 
obtained  only  through  the  slow  and  infrequent  com- 
munication with  Manaos. 

At  every  settlement  sick  people  were  examined  and 
questioned,  blood  smears  taken  and  facts  regarding  the 
diseases  of  the  section  obtained  from  the  more  intelli- 
gent members  of  the  community.  The  number  exam- 
ined at  different  places  and  the  results  of  blood  and 
spleen  examinations  are  indicated  in  Table  I.  On  the 
lower  river,  that  is,  that  part  between  Manaos  and  San 
Isabel,  conditions  were  everywhere  very  much  the  same, 
and  very  deplorable.  In  some  settlements,  such  as,  for 
example,  Carvoeiro  and  Moura,  near  the  mouth  of 
the  Rio  Branco,  scarcely  a  single  healthy  person  could 


MEDICAL  REPORT  67 

be  found.  Practically  all  of  the  children  and  many  of 
the  adults  had  prominent  abdomens  and  big,  hard, 
easily  palpable  spleens  which  in  some  instances  almost 
filled  the  abdomen,  and  all  were  more  or  less  anaemic  and 
weak.  No  one  was  able  to  do  a  real  good  day's  work. 
A  history  of  fever  could  be  obtained  from  many,  but 
there  were  quite  a  number  of  children  with  big  spleens, 
who  according  to  their  parents  had  never  suffered  from 
chills  or  fever.  Our  limited  knowledge  of  the  language 
spoken  made  it  difficult  to  get  accurate  information. 
(Portuguese  is  the  language  of  the  country,  but  many  of 
the  Indians  know  only  their  native  tongue,  —  Tupi- 
guarani  or  Lingo-geral,  as  it  is  called.)  Cases  showing 
acute  symptoms  were  rarely  encountered  and  in  the 
blood  of  these  few,  parasites  were  easily  demonstrated. 
Blood  smears  of  the  majority  of  the  children,  however, 
with  big,  hard  spleens  and  moderate  anaemia  were 
negative,  although  a  prolonged  search  through  several 
smears  sometimes  was  rewarded  by  the  discovery  of 
a  single  organism,  usually  of  the  aestivo-autumnal 
variety. 

That  the  weakness  and  anaemia  and  large  spleens 
were  in  all  cases  the  result  of  chronic  malarial  infection 
is  doubtful.  Examination  of  the  faeces  of  several  very 
anaemic  children  showed  numerous  hookworm  ova. 
The  presence  of  an  eosinophilia  in  at  least  80  per  cent  of 
the  people  is  also  an  indication  of  wide-spread  hookworm 
infection.  In  many  instances,  the  eosinophiles  were 
more  than  20  per  cent.  (See  table.)  The  table  shows 
also  a  high  mononuclear  count,  which  may  be  referable 
to  the  chronic  malaria. 

On  the  upper  portion  of  the  river,  that  is,  between 
San  Isabel  and  San  Gabriel,  the  people  looked  much 
healthier.    Practically  no  big  spleens  were  found  and  a 


68  THE  RICE  EXPEDITION  TO  BRAZIL 

history  of  malaria  was  rarely  obtained.  Blood  smears 
were  negative  in  all  cases. 

It  may  be  of  interest  to  compare  the  manifestations 
of  malaria  such  as  we  found  in  the  Amazon  region  with 
those  observed  in  other  malarious  countries.  Koch  in 
West  Africa  and  New  Guinea,  James,  Stevens,  and 
Christophers  in  India,  Pause  in  East  Africa,  Plehn  in 
the  Kamerun,  Craig  in  the  Philippines,  and  Daniels  in 
Guiana  have  given  good  descriptions  of  malaria  in  the 
respective  countries.  It  is  evident  from  a  review  of 
their  observations,  that  endemic  malaria  may  manifest 
itself  differently  in  different  countries  and  peoples.  At 
least  three  general  types  of  infection  may  be  recognized : 

1.  An  infection  characterized  by  the  presence  of 
numerous  parasites  in  the  blood,  especially  in  children 
under  ten  years,  with  little  or  no  disturbance  in  health. 
The  infection  disappears  without  treatment  as  the  child 
grows  older.  There  is  no  febrile  reaction  and  no  evident 
anaemia  or  weakness.  Koch  describes  the  condition  in 
West  Africa  and  New  Guinea,  where  he  found  organisms 
in  the  blood  of  every  child  under  two  years;  in  48  per 
cent  of  those  between  two  and  five  years  and  23  per 
cent  of  those  between  five  and  ten  years;  none  in  those 
over  ten  years.  Craig  gives  similar  figures  for  native 
Philippine  children;  he  also  found  a  large  percentage 
of  "  healthy  "  adults,  harboring  parasites  in  large  num- 
bers. The  condition  is  also  described  by  James  in  India, 
Pause  in  East  Africa,  and  Plehn  in  the  Kamerun. 
Plehn,  who  saw  many  of  these  "  carriers  "  among  adults, 
says  they  sometimes,  but  rarely,  develop  chills  and 
fever.  When  they  do  it  is  exceptional  to  see  more  than 
one  chill,  even  when  no  quinine  is  administered.  All  of 
the  authors  refer  to  the  state  as  one  of  partial  immunity, 
probably  inherited.    It  may  be  thought  of  as  a  sort  of 


MEDICAL  REPORT  69 

mutual  adaptation  of  host  and  parasite,  or  symbiosis, 
such  as  is  seen  in  the  rat  trypanosome  infections,  where 
the  animal  remains  healthy  even  though  his  blood  be 
teeming  with  parasites.  Not  a  single  example  of  this 
type  of  infection  was  found  by  us  in  Brazil. 

2.  A  chronic  infection  characterized  by  moderate 
anaemia,  weakness,  and  splenic  enlargement  which  is 
sometimes  extreme,  and  by  an  absence  or  great  scarcity 
of  organisms  in  the  circulating  blood.  This  condition 
corresponds  probably  to  the  so-called  "  malarial  cach- 
exia "  of  many  writers.  In  certain  parts  of  India,  this 
type  of  infection  is  very  common.  Koch  does  not  men- 
tion it  in  South  Africa  or  New  Guinea,  and  it  was  not 
seen  by  Craig  in  the  Philippine  natives.  In  the  Amazon 
region  it  is  the  type  of  infection  which  predominates; 
in  fact,  at  least  90  per  cent  of  the  cases  we  saw  could  be 
placed  in  this  group.  The  splenic  enlargement  is  not  a 
constant  feature  according  to  Daniels,  who  says  that  in 
Guiana,  where  malaria  is  extremely  prevalent,  malarial 
spleens  of  great  size  are  rare.  His  observations  are 
based  largely  on  autopsy  findings.  He  thinks  there  may 
be  some  other  factor  than  malaria,  which  is  responsible 
for  the  huge  spleens  sometimes  seen  in  malarious  dis- 
tricts. On  the  Rio  Negro,  as  we  have  pointed  out, 
extreme  splenic  enlargement  was  the  most  striking 
feature  of  the  cases. 

3.  The  ordinary  type  of  infection  as  we  see  it  in 
susceptible  temperate-zone  people  who  visit  the  tropics 
is  periodic  attacks  of  chills  and  fever,  with  progressive 
anaemia,  etc.  With  this  manifestation  of  malaria, 
everyone  is,  of  course,  familiar.  In  the  Philippines  an 
outbreak  of  chills  and  fever  in  a  camp  of  American 
soldiers  led  Craig  to  look  for  the  source  of  infection 
among  the  natives  living  close  by.     Although  none 


70  THE  RICE  EXPEDITION  TO  BRAZIL 

were  having  chills  or  fever  or  looked  chronically  ill, 
Craig  found  any  number  of  "  carriers  "  among  them, 
showing  that  the  striking  difference  in  reaction  in  the 
Americans  and  natives  was  due  to  a  difference  in  host 
and  not  in  the  type  of  malarial  organism  concerned.  In 
our  expedition,  the  single  member  of  the  party  who  con- 
tracted malaria,  developed  typical  chills  and  fever  on 
alternate  days;  while  on  the  lower  Rio  Negro,  where  he 
got  the  infection  (Fig.  24),  chills  and  fever  are  rarely 
seen,  nearly  all  of  the  cases  exhibiting  the  chronic 
cachetic  state. 

Summary 

1.  Malaria  in  chronic  form  is  extremely  prevalent  in 
the  Amazon  Valley,  both  in  the  cities  and  in  the  sparsely 
settled  districts  along  the  rivers.  It  is  the  cause  of  much 
poverty  and  misery,  and  is  one  of  the  chief  causes  of  the 
country's  lack  of  development. 

2.  Examples  of  severe  acute  or  malignant  malaria 
were  not  observed,  but  we  were  told  that  on  certain 
rivers,  especially  the  Madeira,  not  visited  by  us,  fatal 
attacks  were  common.  Statistics  indicating  high 
mortality  of  malaria  in  cities  are  of  doubtful  accuracy. 

3.  A  relatively  small  number  of  cases  examined 
showed  organisms  in  the  circulating  blood,  eleven  out  of 
one  hundred  and  fifty -three  or  7.2  per  cent.  Had  we 
taken  blood  smears  from  the  entire  population,  instead 
of  selecting,  in  many  places,  those  who  looked  ill  or  were 
complaining,  the  percentage  of  positives  would  have 
been  still  smaller.  On  the  other  hand,  a  more  exhaus- 
tive search  through  several  smears  from  each  individual 
would  probably  have  increased  the  number  of  positives. 
Indeed,  a  second  examination  of  twenty  slides  from 
cases  in  which  there  was  a  definite  history  of  malaria 


% 


^  6 

li 

§2 


• 


^ij^T?^y>-4. 


MEDICAL  REPORT  71 

revealed  two  positives  which  had  been  overlooked  on 
first  examination.  In  one,  a  systematic  search  through 
three  smears  revealed  only  a  single  crescent  and  no 
other  form.  Of  the  cases  showing  parasites  in  the  blood, 
the  majority  presented  acute  symptoms,  that  is,  chills 
and  fever.  The  positive  cases  without  fever,  were  all 
aestivo-autumnal  infections. 

4.  Both  tertian  and  aestivo-autumnal  infections  were 
found,  but  no  quartan  forms.  The  three  cases  on  the 
lower  Amazon  showing  parasites  in  the  blood  were  ex- 
amples of  tertian  infection.  On  the  Rio  Negro,  there 
were  fewer  tertian  than  aestivo-autumnal  infections. 
The  one  member  of  our  party  contracting  malaria 
showed  aestivo-autumnal  parasites  in  his  blood.  Though 
an  aestivo-autumnal  infection,  he  had  chills  and  fever 
on  alternate  days,  controlled  by  quinine,  but  exhibiting 
the  common  tendency  to  recurrence  after  his  return  to  a 
temperate  climate. 

5.  On  the  Rio  Negro,  an  interesting  distribution  of 
malaria  was  found.  Infection  is  wide-spread  on  the 
lower  portion  of  the  river,  nearly  every  person  being 
affected.  The  upper  part  of  the  river,  on  the  other 
hand,  is  relatively  free  from  malaria.  A  possible  ex- 
planation of  the  difference  is  found  in  the  presence  of  a 
steamer  line  on  the  lower  river  by  means  oi  which 
infected  people  and  mosquitoes  are  carried  from  place 
to  place. 


72  THE  RICE  EXPEDITION  TO  BRAZIL 

Table  I.    Blood  and  Spleen  Examinations 


Blood 
exam- 
ination 

Posi- 
tive 

Nega- 
tive 

Spleen 
exam- 
ination 

Posi- 
tive 

Nega- 
tive 

Total 
num- 
ber of 
cases 
exam- 
ined 

Monte  Alegre,  Santarem,  and 

Obidos  on  Lower  Amazon. . 

Manaos 

32 

3 

25 

8 

9 

7 

12 

37 
17 

3 

3 

2 

3 
3 

29 
3 

23 
8 
9 
7 
9 

34 
17 

8 

20 

20 

7 

9 

6 

16 

30 
14 

23 

10 
14 

7 

5 
13 

16 
1 

8 

10 

6 

9 
1 
3 

14 
13 

23 

40 
20 

Barcellos,  Lower  Rio  Negro .  . 
Carvoeiro,  Lower  Rio  Negro  . 
Castanha,  Lower  Rio  Negro  . 
Vista  Alegre.Lower  Rio  Negro 
San  Isabel,  Lower  Rio  Negro 
Javari,   Moura,    Providentia, 
and  other  places  on  Lower 
Rio  Negro 

25 

8 

9 

7 

16 

40 

San  Gabriel,  Upper  Rio  Negro 

San  Jos^  and  other  places  on 

Upper  Rio  Negro 

17 

23 

153 

11 

139 

153 

66 

87 

204 

Blood,  positive  ("  Parasite  rate  ") 7.2  % 

Spleen,  positive  ("  Spleen  rate  ") 43.8  % 


Table  XL     Differential  Blood  Counts 

Place  Neutrophiles       Mononuclears     Eosinophiles 

Barcellos,  average  of  20  cases 41.5               48.5  10 

Lower  Rio  Negro,  average  of  20  cases    37.5              46.5  16 

Lower  Rio  Negro,  average  of  35  cases     39.0               46.0  15 

San  Isabel,  average  of  10  cases 37.0              50.0  13 

San  Gabriel,  average  of  15  cases 39.0              40.0  21 

Highest  Count        Lowest  Count 

Neutrophiles 68  8 

Mononuclears 75  20 

Eosinophiles 44  1 


MEDICAL  REPORT 


73 


Splenic  Enlargement 

In  eighty-eight  cases  the  spleen  was  examined  and 
found  enlarged  in  fifty-five.  There  were  various  degrees 
of  this  enlargement,  but  no  case  was  included  under  this 
in  which  the  spleen  was  not  distinctly  palpable.  There 
did  not  seem  to  be  any  definite  relation  between  the 
large  spleens  and  malaria.    In  the  four  tertian   cases 


.-^i     ,,A 


j»:-gfcrs.'.fy  .gz^.  \nmm.-*A- 


Fig.  25.     Children  with  large  spleens. 
Lower  Rio  Negro. 

the  spleen  was  not  palpable,  in  the  four  cases  of  aestivo- 
autumnal  it  was  large  in  two  and  just  palpable  in  two. 
Some  of  the  spleens  examined  were  huge,  larger  than 
any  leucaemic  cases  we  have  seen,  the  dullness  extend- 
ing from  the  mammary  line  well  into  the  pelvis  and  con- 
siderably to  the  right  of  the  umbilicus.  The  spleen 
seemed  rather  flatter  than  in  leucaemia;  in  one  case  the 
edge  could  be  distinctly  grasped  through  the  thin  ab- 
dominal walls  and  it  did  not  seem  to  be  more  than  3  cm. 


74 


THE  RICE  EXPEDITION  TO  BRAZIL 


in  thickness  (Fig.  25).  There  was  no  difficulty  in  the 
determination  of  the  condition,  it  being  necessary  in 
most  cases  merely  to  put  the  hand  on  the  splenic  region 
and  in  some  individuals  when  standing  there  was  a  dis- 
tinct protuberance  of  the  left  side  of  the  abdomen.  It 
was  also  necessary  merel^^  to  -question  the  individuals, 


Fig.  2G.     Enlarged  spleens  in  members  of  the  same  family. 
Lower  Rio  Negro. 

for  all  except  the  children  were  well  aware  of  the  con- 
dition. The  spleen  as  a  rule  was  of  intense  hardness  and 
rarely  tender.  It  was  found  both  in  children  and  in 
adults  (Fig.  26),  the  youngest  case  being  four  years  of 
age,  but  there  was  not  opportunity  for  the  examination 
of  very  young  children. 

All  of  the  cases  in  which  these  spleens  were  found 
showed  a  greater  or  less  degree  of  ill  health  though  most 


MEDICAL  REPORT  75 

of  them  pursued  their  ordinary  vocations.  They  fre- 
quently complained  of  constipation,  which  we  thought 
was  possibly  attributable  to  pressure  upon  the  colon. 
There  was  also  more  or  less  anaemia,  but  there  was 
nothing  in  the  blood  examination  to  throw  light  on  the 
condition.  All  gave  a  history  of  malaria  (paludismo) 
at  some  time  in  the  recent  or  remote  past,  but  for  that 
matter  so  does  everyone  in  the  country.  What  is  the 
relation  of  these  huge  spleens  to  malaria,  if  there  be  any, 
we  do  not  know.  There  was  no  opportunity  for  the 
study  of  the  condition  by  post  mortem  examination. 
As  we  have  known  malaria,  one  of  us  having  had  an 
extensive  experience  with  the  disease  in  Maryland,  such 
spleens  are  not  found.  The  ordinary  condition  is  a  hard 
pigmented  organ,  rarely  exceeding  four  hundred  grams 
in  weight,  and  from  the  apparent  size  of  the  spleen  in 
these  Rio  Negro  cases  it  must  frequently  have  exceeded 
two  thousand  grams.  Thomas,  however,  at  Manaos, 
who  has  seen  many  of  these  cases  of  splenomegaly  from 
the  rivers,  regards  them  as  malarial  and  has  found  often 
only  after  the  examination  of  a  number  of  slides,  either 
single  organisms  or  pigment  in  the  leucocytes.  He 
treats  the  cases  with  enormous  doses  of  quinine  hypo- 
dermically  administered  and  he  thinks  with  benefit. 
The  same  uncertainty  is  seen  in  the  literature.  In  the 
paper  of  Daniels,  "  Enlarged  Spleens  and  Malaria" 
(Thompson,  Yates  Laboratory  Reports,  1901)  based  or 
examinations  in  British  Guiana,  he  says  that  splenic 
enlargement  is  rare  though  the  country  is  very  malarious. 
His  report  is  valuable  as  it  is  based  on  autopsy  records 
and  weights  of  the  spleens  are  given.  Pigmentation  of 
the  spleen,  which  was  found  in  a  high  percentage  of  the 
cases,  bore  no  relation  to  the  size.  He  refers  to  obser- 
vations in  Central  Africa,  where  he  saw  much  malaria 


76 


THE  RICE  EXPEDITION  TO  BRAZIL 


and  there  enlarged  spleen  was  common  in  children  (50 
per  cent  of  cases)  but  he  found  no  enlargement  in  adults. 
He  suggests  that  some  other  factor  than  malaria  is  con- 
cerned in  the  splenomegaly  of  malarious  districts.  We 
append  the  valuable  table  of  Daniels. 

Weight  of  Spleens  at  Autopsy 


East 
Indies 

N.N. 
of  B.  G.i 

Aboriginals 
of  Brit.  G. 

Immigrant 
negroes 

Europeans 
in  Brit.  G. 

N-P2 

p3 

N-P 

P 

N-P 

P 

N-P 

P 

N-P 

P 

Number  of  cases .... 

345 

80 

171 

57 

9 

4 

65 

63 

12 

7 

% 

% 

% 

% 

% 

% 

% 

% 

% 

% 

Under  150  gr 

4.9 

11.2 

33.9 

35.2 

46.1 

31.9 

25.5 

150-300  gr 

18.5 

32.5 

47.3 

42.6 

22.2 

25 

32.3 

41.2 

41.6 

300-450  gr 

24.0 

23.7 

9.9 

14.8 

11.1 

6.1 

14.2 

8.3 

57.1 

450-600  gr 

15.6 

20.0 

6.4 

5.5 

22.2 

50 

12.2 

6.3 

16.6 

14.2 

600-750  gr 

12.7 

2.5 

1.2 

11.1 

4.7 

14.2 

750-900  gr 

9.8 

2.5 

.58 

14.2 

900-1200  gr 

5.2 

5.0 

.58 

1.6 

1200-1500  gr 

5.5 

25 

1.5 

1500-1800  gr 

2.0 

Over  1800  gr 

2.0 

2.5 

11.1 

1  Native  negroes  of  British  Guiana.  '  Non-pigmented. 

Pigmented  spleens  =  malarial  spleens. 


'  Pigmented. 


Craig,  The  Malarial  Fevers,  1909,  says  enlargement 
during  acute  attacks  is  not  constant;  in  most  cases  the 
spleen  is  not  palpable.  But  where  the  condition  is 
chronic  and  especially  if  there  have  been  many  relapses, 
the  splenic  enlargement  is  generally  noticeable;  the 
organ  is  palpable  and  may  extend  to  the  umbilicus.  In 
aestivo-autumnal  infections  a  palpable  spleen  is  more 
often  found,  and  in  old  infections  the  spleen  is  hard 
and  presents  a  well  defined  border.  Under  malarial 
cachexia  he  says:  "  Enlargement  of  the  spleen  is  a  com- 
mon condition  but  not  an  invariable  one.  I  have 
observed  many  cases  of  chronic  malarial  infection  in 


MEDICAL  REPORT  77 

which  the  spleen  was  but  little  if  any  enlarged.  In  old 
cases  the  organ  may  be  enormously  enlarged,  reaching 
as  low  as  the  crest  of  the  ilium,  but  as  a  rule  it  does  not 
extend  more  than  4-8  cm.  below  the  borders  of  the  ribs. 
It  is  firm  but  not  painful  on  palpation."  Deaderick, 
A  Practical  Study  of  Malaria,  1909,  says:  "  The  spleen 
may -be  of  normal  proportions  in  mild  cases  but  is 
usually  enlarged,  sometimes  enormously  so,  passing  the 
median  line  of  the  abdomen  and  the  iliac  crest.  In  the 
malarial  cachexia  the  most  pronounced  phenomena  are 
the  anaemia  and  the  enlarged  spleen.  The  spleen  often 
extends  to  the  umbilicus  and  to  the  crest  of  the  ilium, 
sometimes  beyond.  It  is  hard,  the  anterior  border  pre- 
sents a  sharp  edge  and  pain  and  tenderness  on  pressure 
are  not  always  felt."  He  gives  a  number  of  photographs 
of  men  and  boys  showing  spleens  quite  comparable  to 
those  we  saw. 

Stephens  and  Christophers,  "  The  Relation  between 
the  Large  Spleen  and  Parasitic  Infection,"  Reports  to 
the  Malarial  Committee,  Royal  Society  of  London,  1902, 
reach  these  conclusions:  (1)  "A  high  endemic  index 
(as  determined  by  blood  examinations  of  children)  may 
exist  without  any  appreciative  spleen  rate  (Africa). 
(2)  A  high  spleen  rate  may  exist  in  adults  without  a 
corresponding  parasite  infection.  (3)  In  India  (Bengal) 
among  children  a  high  spleen  rate  is  a  fair  index  of  the 
parasitic  infection.  (4)  The  spleen  rate,  unlike  the 
parasitic  rate,  increases  up  to  a  certain  age  limit  and 
may  be  considerable  when  the  parasite  rate  is  nil." 
They  examined  eighty  cases  in  the  native  hospitals  of 
Calcutta  with  enlargement  of  the  spleen  varying  from 
two  or  three  fingers  breadth  below  the  ribs  to  that  of  a 
spleen  filling  the  whole  left  side  of  the  abdomen  and 
reaching  to  the  pubes.    In  none  of  these  cases  did  they 


78  THE  RICE  EXPEDITION  TO  BRAZIL 

find  parasites  or  pigmented  leucocytes  or  any  mono- 
nuclear increase  such  as  they  showed  in  previous  reports 
to  be  characteristic  of  recent  infection.  In  six  post 
mortem  examinations  on  such  cases  no  parasites  were 
found  in  either  spleen  or  bone  marrow.  They  quote 
from  Plehn,  Die  Kamerun  Kuste,  who  says  that  in  the 
majority  of  the  cases  examined  by  him  on  the  Kamerun 
coast  the  spleen  is  not  larger  than  in  cases  of  typhoid 
seen  in  Germany,  and  may  be  much  smaller  than  this. 
Annett,  Dutton,  and  Elliot,  "  Report  of  Malarial 
Expedition  to  Nigeria  "  (Thompson,  Yates  Laboratory 
Reports,  1902)  do  not  mention  splenic  enlargement  as 
occurring  in  the  natives.  Darling,  in  his  studies  of  the 
diseases  at  the  Ancon  Hospital  in  Panama,  has  seen 
many  of  these  huge  spleens,  they  being  known  there 
as  the  Colombian  spleen,  and  at  autopsies  he  made 
smears  from  the  spleens.  In  three  cases  he  found  in  the 
greatly  enlarged  spleen  and  in  the  liver  numbers  of 
organisms  which  he  described  under  the  name  Histo- 
plasma  Capsulatum  {Jour.  Exper.  Med.,  vol.  xi,  1909) 
and  which  he  thinks  differ  from  the  Leishmania  of  Kala 
Azar.  Two  of  the  cases  were  Martinique  negroes  and 
one  a  Chinaman  who  had  lived  fifteen  years  on  the 
Isthmus.  Darling  regards  as  the  main  difference  be- 
tween his  organism  and  that  of  Kala  Azar,  the  absence 
of  the  second  nucleus.  It  should  be  remarked  that  the 
presence  of  this,  both  in  smears  and  sections  of  organs 
may  easily  be  obscured  and  a  comparison  of  Darling's 
photographs  with  sections  from  typical  cases  of  Kala 
Azar  leaves  little  doubt  in  the  mind  that  Darling's 
cases  were  really  Kala  Azar.  In  the  other  cases  exam- 
ined Darling  found  no  organisms.  Ross,  who  visited 
the  Isthmus  in  1904  and  studied  the  cases  of  enlarged 
spleen  with  reference  to  the  symptom  group  of  Kala 


MEDICAL  REPORT  79 

Azar,  did  not  find  this.  In  addition  to  the  cases  of 
enlarged  spleens  which  we  found  on  the  Rio  Negro,  we 
saw  great  numbers  of  similar  cases  in  the  hospitals  of 
Manaos  and  Para,  particularly  in  the  latter.  They  came 
from  the  upper  waters  of  the  rivers  and  were  com- 
plicated both  by  ulcers  and  malaria,  but  there  seemed 
no  interrelation.  Although  from  Darling's  report  it 
seems  more  than  probable  that  certain  of  these  cases 
may  be  Kala  Azar,  this  cannot  be  held  to  be  the  com- 
mon cause.  We  think  that  the  most  of  these  cases 
belong  to  that  very  obscure  condition  known  as  tropical 
splenomegaly. 

The  Upper  Rio  Negro 

Very  different  were  the  conditions  found  along  the 
upper  river  about  San  Isabel.  As  we  have  said,  the  cur- 
rent is  here  more  rapid,  with  the  exception  of  certain 
stretches  where  the  conditions  of  the  lower  river  are 
approached,  and  the  banks,  islands,  and  river  bed  are 
granite.  There  is  even  less  population  than  below,  and 
little  pretense  to  the  formation  of  villages,  there  being 
as  a  rule  merely  the  more  or  less  extensive  sitios  of  the 
rubber  merchants  with  a  few  houses  of  dependents. 
The  population  in  these  places  varies  depending  upon 
the  season  of  rubber  gathering.  The  extent  of  country 
owned  or  rather  controlled  by  each  of  the  rubber  mer- 
chants and  the  number  of  persons  employed  in  rubber 
gathering  varies.  The  gatherers,  seringueros,  are  chiefly 
the  Indians  of  the  region,  who  seem  to  go  with  the  land, 
and  who  when  weaned  from  their  forest  life  become 
practically  slaves  and  totally  dependent  upon  the 
trader.  Rum,  which  they  soon  learn  to  regard  as  a 
primal  necessity,  is  the  active  agent  in  their  reduction 
to  such  a  condition,  but  civilization  offers  other  baits  as 


80  THE  RICE  EXPEDITION  TO  BRAZIL 

well,  such  as  small  sewing  machines,  music  boxes,  etc. 
Once  when  travelling  on  the  river  with  a  merchant,  a 
seringuero  of  wretched  appearance,  pale  and  anaemic, 
presented  a  list  of  articles  which  he  wished  advanced, 
such  as  sugar,  coffee,  mandioca,  etc.,  but  as  the  poor 
wretch  was  already  in  arrears  he  was  given  merely  the 
necessities  of  life,  which  consisted  of  a  gallon  of  rum  and 


Fig.  26a.     Children  at  San  Gabriel.    No  splenic  enlargement. 

a  package  of  matches.     As  many  as  three  thousand 
gatherers  may  be  attached  to  a  single  station. 

On  this  upper  river  there  were  seventeen  examina- 
tions of  blood,  none  of  them  positive.  There  was  little 
complaint  of  malaria,  although  we  were  told  that  cases 
occurred  at  the  end  of  the  rainy  season.  Mosquitoes  we 
found  not  at  all,  although  we  slept  for  the  most  part  in 
native  houses,  nor  in  the  numerous  examinations  of  the 
people  was  there  evidence  of  these  having  been  bitten. 
The  contrast  between  the  populations  was  striking;  on 
the  upper  river  the  people  were  well  nourished  and 
seemingly  healthy.    The  single  case  of  real  illness  was 


MEDICAL  REPORT  81 

that  of  a  merchant  whose  business  in  collecting  rubber 
led  him  to  take  frequent  trips  below  San  Isabel  and  up 
various  rivers.  He  gave  a  history  of  malarial  attacks, 
but  the  principal  trouble  seemed  cirrhosis  of  the  liver. 
In  thirty -eight  cases  the  spleen  was  examined  and  found 
to  be  slightly  enlarged  in  one.  This  was  in  a  child  in  San 
Gabriel  and  was  associated  with  slight  enlargement  of 
the  liver  and  slight  ascites  with  no  history  of  malaria. 

The  very  common  condition  of  enlarged  abdomen  in 
the  children  was  very  evident  and  seemed  to  be  due  to 
gaseous  distension  (Fig.  26a).  In  this  form  of  disten- 
sion the  thorax  is  bell  shaped,  greatly  dilated  below,  due 
to  the  thrusting  upwards  of  the  abdominal  contents,  and 
the  liver  dullness  is  not  so  perceptible  as  in  the  normal. 

Mosquitoes 

It  seems  to  us  extraordinary  that  two  regions  on  the 
same  river  and  presenting  such  similar  physical  char- 
acteristics should  so  differ  in  health  as  the  region  below 
and  that  above  San  Isabel.  It  is  true  that  the  river 
below  San  Isabel  is  more  sluggish  with  great  lake-like 
expansions  often  twenty  miles  or  more  wide  with  numer- 
ous low  islands,  but  above  San  Isabel  there  are  many 
such  places  and  the  life  of  the  people  in  the  two  regions 
is  practically  the  same.  There  would  seem  to  be  every 
possible  opportunity  for  the  breeding  of  mosquitoes  and 
the  extension  of  malaria  in  the  two  places.  There  is 
water  in  pools  formed  as  the  river  sinks,  water  collects 
from  rains  in  rock  depressions,  and  the  irregularities  of 
epiphytic  plants  holds  it;  that  mosquitoes  can  breed 
in  such  places  was  shown  by  our  finding  numerous 
embryos  in  the  pot  holes  in  the  granite  at  San  Gabriel 
where  we  never  saw  an  adult  mosquito  and  where  we 
found  no  malaria. 


82  THE  RICE  EXPEDITION  TO  BRAZIL 

The  ascent  of  the  Rio  Negro  to  San  Isabel  was  made 
on  a  river  steamer,  we  being  the  only  passengers,  and 
the  steamer  had  been  completely  cleaned  for  our  use. 
On  this  we  slept  without  nets,  ate  on  deck  and  sat  there 
at  night,  and  not  a  mosquito  was  seen.  On  the  return 
from  San  Isabel  on  the  launch  a  few  mosquitoes  were 
found  and  one  of  the  party  contracted  malaria.  One  of 
the  party  returned  on  the  regular  river  steamer  from 
San  Isabel  and  found  very  different  conditions.  This 
steamer,  a  larger  boat  than  that  on  which  we  ascended, 
was  of  shallow  draft  and  propelled  by  a  stern  wheel. 
There  were  two  decks,  the  lower  occupied  by  the  ma- 
chinery, the  crew  and  the  galley,  together  with  freight 
and  the  animals  carried  along  to  be  slaughtered  for 
food.  The  officers  and  passengers  occupied  cabins 
which  ran  in  a  double  row  in  the  middle  of  the  upper 
deck  and  aft  of  these  the  deck  was  open,  giving  a  space 
for  eating  and  sitting.  The  oflBcers  and  most  of  the  pas- 
sengers slept  in  hammocks  slung  from  supports  on  the 
upper  deck  and  were  not  troubled  with  mosquitoes. 
The  cabins,  however,  were  so  filled  with  them  that  sleep 
was  impossible.  They  hid  in  dark  corners  and  beneath 
the  beds  and  could  not  be  driven  out.  They  were  exclu- 
sively nocturnal  and  one  could  sleep  in  the  cabin  during 
the  day  without  being  bitten.  The  mosquitoes  are 
small,  dark  in  color,  and  their  bites  were  thickly  placed 
on  exposed  surfaces,  produced  little  swelling  and  small 
areas  of  hyperaemia  and  hemorrhage.  A  well  bitten 
foot  and  ankle  bone  has  some  resemblance  to  a  severe 
typhus  rash. 

After  a  short  stay  in  Manaos  the  same  steamer  was 
taken  for  a  trip  up  the  Autaz  river,  which  took  several 
days.  Here  the  same  conditions  were  found.  The 
cabins  swarmed  with  mosquitoes  but  there  was  little 


MEDICAL  REPORT  83 

annoyance  when  sleeping  on  deck  in  the  open.  The 
beginning  of  the  high  water  was  seen  here  and  large 
areas  of  land  were  flooded. 

No  blood  examinations  were  made  but  some  of  the 
people  at  landings  said  they  had  malaria  and  the  popu- 
lation looked  much  like  that  on  the  lower  Rio  Negro. 
Two  members  of  the  crew,  whose  duties  involved  night 
work  in  their  cabins,  had  chronic  malaria  and  in  one 
there  was  an  acute  exacerbation. 

The  conditions  on  the  upper  and  lower  Rio  Negro 
being  so  similar,  with  the  exception  of  the  steam  trans- 
portation on  the  lower  river,  it  occurred  to  us  after 
experience  on  the  river  steamers  that  this  might  have 
some  influence  on  the  distribution  of  disease.  The  boat 
makes  many  stops  for  wood  and  at  the  depots  of  freight 
collection  and  distribution.  Nothing  goes  on  with 
rapidity;  the  stops  are  long,  the  boat  often  remaining 
all  night  alongside  the  bank  and  several  days  are  occu- 
pied at  San  Isabel.  The  arrival  of  the  boat  is  an  event, 
the  inhabitants  come  on  board  and  sit  around  resting, 
conversing,  and  enjoying  the  alcoholic  cheer  which  the 
boat  provides.  The  steamer  gradually  collects  mos- 
quitoes; a  few  come  on  board  at  Manaos  and  other 
places  and  all  stay,  finding  undisturbed  abodes  in 
the  cabins.  Probably  every  passenger  who  comes  on 
board,  particularly  if  the  night  be  passed  in  a  cabin,  and 
this  is  generally  the  case  with  the  women,  becomes  in- 
fected or  if  so  receives  a  fresh  dose.  The  same  is  true 
but  to  a  less  extent  with  the  visitors.  Whether  mosqui- 
toes breed  on  the  boat  is  uncertain.  The  water  is  taken 
from  the  river  off  the  bow  of  the  steamer  and  pumped 
into  closed  iron  tanks  on  the  deck  roof.  The  lower  deck 
is  usually  wet  and  in  the  confused  mass  of  machinery, 
animals,  cargo,  and  crew  it  would  easily  be  possible  for 


84  THE  RICE  EXPEDITION  TO  BRAZIL 

small  pools  to  form  in  out  of  the  way  places  and  serve 
for  breeding,  but  such  were  not  seen.  The  mosquitoes 
find  abundant  food  in  the  humans,  in  the  carcasses  of 
the  slaughtered  cattle  which  are  hung  on  the  upper 
deck  until  used,  and  in  the  fruit  which  is  carried.  At 
the  landing  places  the  disease  may  be  still  further  dis- 
seminated by  the  freighting  canoes  and  launches  which 
gather  to  meet  the  steamer.  The  prevalence  of  the 
disease  on  the  lower  river  is  also  favored  by  the  greater 
population  and  its  collection  in  villages. 

Diseases  of  the  Indians 

As  we  have  observed  the  Indians  in  the  hospitals  in 
the  Amazonian  cities  and  about  the  villages  on  the  Rio 
Negro,  there  does  not  seem  to  be  any  difference  in  dis- 
eases as  compared  with  the  whites.  Concerning  the 
diseases  of  the  remote  forest  Indians,  we  know  practi- 
cally nothing.  There  have  been  but  few  explorers 
among  them,  and  these  have  generally  been  more  inter- 
ested in  their  own  ills  than  in  those  of  the  Indians; 
usually  being  devoid  of  medical  training,  the  descrip- 
tions of  diseases  which  they  have  given  are  of  little 
value.  The  matter  is  of  great  importance,  particularly 
in  regard  to  malaria,  for  there  are  Indian  tribes  in  the 
interior  who  have  never  come  in  contact  with  whites. 
Rice,  whose  exploration  of  the  Uaupes  was  one  of  the 
most  carefully  conducted  expeditions  in  Brazil,  has 
given  some  account  of  the  diseases  of  the  forest  Indians. 
(Rice,  "River  Uaupes,"  Roy.  Geog.  Soc.  Jour.,  35, 1910). 
He  says,  regarding  the  Uaupes  Indians,  "  They  are  curi- 
ously free  from  the  most  dreaded  diseases  of  civilization, 
such  as  cancer,  syphilis,  and  appendicitis.  Fever  due  to 
malarial  infection  or  simulating  such  is  common,  as  are 
large  spleens  and  livers.    In  the  territory  of  the  upper 


MEDICAL  REPORT  85 

river  mosquitoes  abound,  and  rest  at  night  is  impossible 
without  nets.  On  the  lower  river  they  are  absent  for 
the  most  part,  and  infection  due  to  malarial  parasites 
must  be  transmitted  by  a  host  or  means  other  than  the 
anopheles.  One  case  I  saw  of  possible  leprosy,  and 
sporadic  cases  of  beriberi  are  frequent.  They  are  very 
susceptible  to  and  dread  influenza  or  deflux  or  catarrho, 
as  it  is  variously  termed.  Eye  diseases  are  extremely 
common,  especially  conjunctivitis.  Infant  mortality  is 
high  on  account  of  intestinal  diseases  of  protozoan  or 
helminthic  origin.  Both  carate  or  pinta  and  eczematous 
conditions  are  common.  Bronchitis  is  frequent,  due  to 
the  Indians'  heedless  exposure.  Rheumatism  is  notice- 
ably absent  and  so  is  tuberculosis,  though  with  the 
growth  of  the  rubber  industry  and  the  increased  inva- 
sion of  the  white  man,  with  consequent  hybridization 
will  come  his  two  aborigine  annihilators,  syphilis  and 
tuberculosis." 

In  a  later  exploration,  in  which  he  went  from  Bogota 
to  San  Martin  and  thence  through  the  Northwest 
Amazon  basin  along  the  Inirida  and  Icana  rivers  to  the 
Rio  Negro,  he  speaks  at  more  length  concerning  the  dis- 
eases encountered.  San  Martin,  inhabited  by  a  mixed 
race  of  Indian  and  white,  is  a  centre  for  the  rubber  of  the 
district  and  diseases  contracted  along  the  upper  waters 
of  the  rivers  are  brought  there.  He  found  malarial  para- 
sites in  two  hundred  and  fifty  examinations  of  the  blood 
of  adults  and  children.  Cariti  or  pinta  was  also  very 
common.  At  San  Jose,  on  the  Guaviare,  he  found  fevers 
and  ulcers  were  common,  and  also  a  peculiar  and  painful 
disease  of  the  toes,  locally  called  sabauones.  This 
begins  with  intense  itching,  especially  between  the  toes, 
and  a  slight  colorless  exudate  of  foul  odor.  The  skin 
turns  white,  sloughs  off,  acute  inflammation  ensues,  and 


86  THE  RICE  EXPEDITION  TO  BRAZIL 

the  underlying  tissue  becomes  pulpy.  Any  attempt  to 
move  the  foot  or  even  stand  on  it  is  productive  of  a  most 
intense  and  unbearable  pain.  At  Calamar  he  found  the 
majority  of  the  people  ill,  and  he  himself  acquired  a 
tropical  ulcer,  the  cicatrix  of  which  is  shown  (Fig.  31). 
On  the  Papunaua,  a  black  water  stream  by  which  he 
passed  from  the  Inirida  to  the  Icana  river,  he  found, 
much  disease  among  the  Indians  and  the  blood  invari- 
ably showed  tertian  malarial  organisms.  The  Icana 
would  seem  to  be  a  much  healthier  stream  than  the 
Inirida  and  he  makes  no  mention  of  diseases  encoun- 
tered here.  It  is  interesting  that  he  found  malaria  in 
the  maloccas  of  tribes  which  had  no  outside  contact,  but 
the  possibility  of  carriers  could  not  well  be  excluded. 
He  says  nothing  here  in  regard  to  splenic  enlargement. 

Chandless  ("  Exploration  of  the  Purus,"  Roy.  Geog. 
Soc.  Jour.,  36,  1866)  speaks  of  the  great  seasonal  varia- 
tion in  health  along  this  river.  At  the  period  of  his 
exploration  it  was  healthy,  but  eight  years  previously 
it  was  very  unhealthy.  He  mentions  a  form  of  skin 
disease  as  common  among  the  Indians,  but  gives  no 
description  of  it.  He  says  that  Indians  of  other  tribes 
have  caught  it  and  one  white  man,  but  it  is  not  commun- 
icated by  ordinary  contact. 

Whiffin  (The  Northivest  Amazon,  1908)  has  made  a 
careful  study  of  the  remote  Indians,  and  naturally  this 
embraces  something  of  their  diseases  and  medical  prac- 
tices. These  Indians  are  cowards  in  sickness,  believing 
it  is  due  not  to  natural  causes,  but  to  charms  and  poison- 
ings. Poisoning  is  common.  Should  an  infectious  dis- 
ease appear,  those  attacked  are  abandoned.  Malarial 
fevers  are  common,  chest  diseases  rare,  and  respiratory 
diseases  unknown.  There  is  also  no  venereal  disease. 
Lice  are  universal;    ring-worm  and  intestinal  parasites 


MEDICAL  REPORT  87 

are  very  common  troubles,  and  chiggoes,  always  found 
in  the  houses,  are  a  great  pest.  Regions  have  been 
devastated  by  smallpox,  which  was  introduced  by  the 
rubber  gatherers.  Beriberi  does  not  attack  Indians,  but 
pinta  is  not  uncommon.  Small  families  are  the  rule, 
children  are  not  born  frequently,  two  and  a  half  years 
being  the  average  between  births,  and  the  infant  mor- 
tality is  high.  Twin  births  and  congenital  deformities 
are  said  to  be  unknown.  These  would  be  regarded  as 
disgraceful,  as  simulating  conditions  which  may  be 
found  in  animals,  and  their  absence  may  be  due  to  the 
habit  of  washing  the  child  immediately  after  birth,  in 
the  river,  giving  facility  for  losing  an  undesirable  family 
connection. 

Fawcett  ("  Explorations  in  Bolivia,"  Roy.  Geog.  Soc. 
Jour.,  35, 1910)  found  many  interesting  conditions  in  the 
country  travelled,  but  says  little  about  the  diseases  of 
the  Indians.  Espundia,  an  ulcerous  sore  difficult  to 
heal  and  said  to  be  due  to  the  scratching  of  insect  bites, 
was  frequently  encountered.  The  virus  of  this  may  be 
carried  to  the  nose,  causing  sloughing  of  the  cartilage. 
He  also  mentions  the  great  variation  in  the  sickness 
along  the  rivers  in  different  years. 

It  is  not  impossible  that  there  are  preserved  some- 
where in  the  reports  from  the  old  Jesuit  missions,  which 
were  scattered  everywhere  through  the  country,  inter- 
esting and  accurate  descriptions  of  the  Indians  before 
the  trader  came  into  contact  with  them.  The  great 
explorers  of  the  preceding  century,  Humboldt,  Spix,  and 
Martins,  Wallace,  Spruce,  and  Bates,  have  little  or 
nothing  on  the  subject  of  Indian  diseases.^  The  condi- 
tions shown  in  the  very  meagre  information  we  have  are 

^  Martius,  however,  has  given  a  very  graphic  description  of  the  ravages 
of  smallpox  which  he  encountered  on  the  Peruvian  border. 


88 


THE  RICE  EXPEDITION  TO  BRAZIL 


about  what  we  might  expect.  We  should  expect  the 
incidence  of  malaria,  especially  in  the  latent  and  chronic 
forms,  to  be  high,  for  the  life  of  the  Indians  would  favor 
it.  The  common  house  or  malocca  certainly  offers  ideal 
conditions,  in  facilities  for  harboring  anopheles  and 
there  must  be  sufficient  intercourse  to  give  some  of 
these  a  chance  for  infection. 

Although  reliable  statistics  are  absent,  there  seems  no 
doubt  of  a  great  diminution  in  the  numbers  of  the  Indian 


'"    '     J  '1 

■:.>-J    i" 

:^^^ 

^^^ 

ft 

■  -"^-„|g^ 

Fig.  27.     Paralytic  form  of  Beriberi. 
Iquitos. 

population.  There  have  been  many  factors  in  the  dim- 
inution, but  disease,  particularly  smallpox,  has  probably 
been  the  most  important.  To  the  factor  of  disease  must 
be  added  inter-tribal  wars,  which  were  encouraged  by  the 
whites  with  the  view  of  procuring  slaves  from  the  victors. 
The  commercial  exploitation  at  the  present  time,  which 
increases  alcoholism,  breaks  up  the  family  life,  and  by 
increasing  intercourse  gives  greater  opportunity  for  the 
extension  of  infection,  plays  an  important  part  in  exter- 
mination. The  Indians  are  without  protection,  practi- 
cally at  the  mercy  of  a  commercial  people  in  whom  the 
traditions  of  the  exploitation  of  weaker  peoples  are 
firmly  fixed.  It  would  seem  that  man  can  always  be 
trusted  to  kill  the  goose  which  lays  the  golden  egg. 


MEDICAL  REPORT  89 

Leprosy 

This  is  undoubtedly  a  wide-spread  disease  in  the 
region,  but  how  extensive  there  is  no  means  of  knowing. 
There  are  leper  asylums  attached  to  the  cities  and  the 
principal  towns,  but  there  is  no  pretense  to  strict  seg- 
regation. The  cases  we  saw  were  of  the  ordinary 
tubercular  and  mutilating  forms. 

Beriberi 

But  one  case  of  this  (Fig.  27)  a  well  marked  paralytic 
form,  was  seen  in  the  hospital  at  Iquitos.  If  this  is  a 
disease  dependent  upon  food  conditions  the  variety  of 
food  and  the  large  use  of  fruit  would  seem  not  to  favor 
it. 

Yaws  and  other  Forms  of  Skin  Diseases 

We  saw  no  cases  which  were  diagnosed  as  yaws  and 
no  cases  which  we  recognized  as  this,  but  it  might  readily 
have  been  overlooked.  Pian  was  not  uncommon  both 
in  the  hospital  cases  and  along  the  rivers.  There  were 
a  number  of  cases  of  skin  disease,  the  diagnosis  of  which 
we  could  not  determine. 

FiLARIASIS 

In  spite  of  the  frequency  of  elephantiasis  in  Rio  and 
the  southern  states  of  Brazil  we  saw  in  the  Amazonas  no 
cases  either  in  the  hospitals  or  among  the  people.  We 
do  not  know  whether  there  have  been  any  systematic 
blood  examinations  to  determine  the  absence  of  filariasis. 

Other  Diseases 

At  San  Isabel  we  saw  one  typical  case  of  acromegaly 
in  a  mulatto. 


90  THE  RICE  EXPEDITION  TO  BRAZIL 

Ulcers 

One  of  the  most  common  conditions  found  in  the 
hospitals  of  Para,  Manaos,  and  Iquitos,  were  ulcers, 
usually  on  the  lower  extremities  and  varying  in  extent 
and  character.  The  ulcer  patients  form  a  large  per- 
centage of  the  hospital  cases  and  generally  come  from 
the  head  waters  of  the  rivers,  most  of  those  in  Manaos 
from  the  Madeira.  The  subjects  were  usually  badly 
nourished,  anaemic,  and  had  in  addition  malaria,  and 
the  huge  spleens  common  to  these  regions.  The  spleens 
were  particularly  noticeable  in  the  ulcer  ward  in  Para. 

These  ulcers  have  of  late  acquired  a  greater  interest, 
due  to  the  discovery  in  them  of  Leishmania,  which 
places  them  in  the  category  of  the  Button  of  the  Orient. 
There  is  an  extensive  literature  on  the  subject,  most  of 
which  is  contained  in  the  Bulletins  of  the  French  Society 
of  Tropical  Medicine.  The  specific  character  of  cer- 
tain of  these  ulcers  and  the  organisms  associated  with 
them  were  first  noticed  among  the  railroad  workmen  in 
Bauru,  a  town  in  the  western  part  of  San  Paulo,  the 
most  southerly  state  of  Brazil.  Lindenberg  {Bull,  de  la 
soc.  de  path,  exot.,  vol.  ii,  1909)  describes  the  ulcers  as 
occurring  chiefly  on  parts  of  the  body  which  are  uncov- 
ered. The  ulcers  are  round  or  oval,  sharply  cut,  with 
projected  edges  of  a  deep  violet  color,  the  base  covered 
with  deep  vascular  vegetations  or  with  an  adherent 
crust.  Sections  of  the  old  ulcers  showed  nothing,  but 
in  one  case  in  which  there  were  several  small  ulcers 
1.5  cm.  in  diameter  and  of  one  month  duration,  the  sec- 
tions showed  the  organisms  first  described  by  Wright, 
and  in  scrapings  from  other  ulcers  the  same  organisms 
were  found.  In  1895  Moreira  described  similar  ulcers  in 
Bahai,  but  did  not  recognize  the  parasite.    Lindenberg's 


MEDICAL  REPORT  91 

results  were  confirmed  in  a  following  article  by  Carini 
and  Paranhos,  who  think  the  disease  follows  the  prick 
of  an  insect  and  appears  first  as  a  papule  which  later 
develops  into  an  ulcer  and  becomes  covered  with  a  thick 
crust.    Carini  and  Splendore  in  the  same  journal,  1911 
and  1912,  describe  ulcers  on  the  mucous  membrane  of 
the  nose  and  hard  palate,  which  follow  the  ulcers  of  the 
skin.     In  Carini's  case  "the  surface  of  the  palate  was 
ulcerated,  the  ulcer  covered  with  irregular,  prominent, 
firm  granulations.     There  were  also  erosions  covered 
with   an   adherent   yellow   exudate.     The   uvula   was 
destroyed,  and  its  place  taken  by  a  granulating  surface. 
On  the  inner  surface  of  the  left  nostril  there  was  an 
oedematous  swelling  covered  by  a  thick  crust  which 
almost  occluded  the  nostril.    Various  travellers  in  Peru 
have  spoken  of  similar  ulcers  of  the  mouth  and  nose, 
known  there  under  the  name  of  Espundia,  and  Escomel 
(Bull,  de  la  soc.  de  'path,  exot.,  1911)  gives  a  full  descrip- 
tion of  the  disease.     It  follows  after  a  variable  time, 
which  may  be  months  or  years,  the  ulcers  on  the  skin, 
which  he  regards  as  the  chancre  or  initial  lesion.     He 
found  no  organisms  but  in  excised  areas  from  the  palatal 
lesions  which  he  sent  Lavaran  the  latter  found  Leish- 
mania  both  free  and  enclosed  in  cells.    The  organisms 
are  round,  of  the  same  size  as  the  Leishmania,  have  a 
nucleus  and  centrosome,  but  differ  from  the  Leishmania 
of  Oriental  Button  in  that  the  nucleus  is  flattened  and 
closely  applied  to  the  wall.    The  organism  was  present 
in  very  small  numbers  and  he  regards  it  as  a  variety  of 
the  Leishmania  tropica.     In  other  parts  of  Peru  the 
condition  is  known  as  Uta  and  material  from  these  cases 
was  studied  by  the  expedition  to  Peru  carried  out  by 
the  Harvard  Department  of  Tropical  Medicine  in  1913, 
and  the  organisms  in  small  numbers  were  found  both 


92  THE  RICE  EXPEDITION  TO  BRAZIL 

in  smears  and  sections:  ("  Report  of  the  First  Expedi- 
tion to  South  America,  1913").  Similar  conditions  have 
been  described  in  other  parts  of  Brazil,  in  Peru,  in  Para- 
guay, and  on  the  Isthmus.  The  Espundia  is  well  known, 
not  only  in  Peru,  but  in  Bolivia,  Ecuador,  and  Colom- 
bia. The  best  clinical  description  of  the  ulcers  is  that 
given  by  Matta  of  Manaos  {Bull,  de  la  soc.  de  path, 
exot,  vol.  ix,  1916).  "  The  ulcer  begins  with  itching  of 
the  part,  followed  by  elevated  papules.  Two  to  five 
days  afterward  small  pustules,  in  size  from  the  head  of 
a  pin  to  that  of  a  grain  of  wheat  form,  which  rupture 
and  discharge  a  purulent  yellowish  gelatinous  material. 
The  small  ulcers  so  formed  extend  by  infection  of  the 
surrounding  surface,  by  the  secretion,  and  also  by 
means  of  the  lymphatics.  The  ulcer  becomes  covered 
by  a  crust,  beneath  which  a  quantity  of  intensely  foetid 
pus  is  retained.  On  removing  the  crust  there  appears  a 
deep  ulcer  with  projecting  edges.  Cases  rarely  recover 
spontaneously,  leaving  large  permanent  cicatrices."  On 
one  patient  Matta  found  fifty-one  lesions  which  exhib- 
ited every  phase  of  development  up  to  cicatrization. 

There  is  a  general  inclination  to  attribute  the  cause  to 
insect  bites,  and  all  the  common  insects  with  the  excep- 
tion of  the  mosquito  have  been  accused  in  turn.  Where 
there  is  a  prominent  and  disagreeable  insect  in  a  region 
and  ulcers  at  the  same  time  are  common,  the  additional 
burden  of  the  ulcers  is  loaded  upon  the  shoulders  of  the 
insect.  It  has  been  given  a  great  variety  of  local  names 
and  is  generally  recognized  by  the  common  people  as  a 
definite  disease.  It  occurs  most  generally  in  the  virgin 
forests  of  the  upper  sources  of  the  rivers,  though  cases 
occur  in  the  vicinity  of  Para  and  Manaos.  It  is  partic- 
ularly common  among  the  rubber  gatherers  who  are 
most  exposed  to  insect  bites,  have  chronic  malaria,  are 


MEDICAL  REPORT 


93 


badly  nourished,  and  live  miserably  in  the  forest.  One 
point  always  alleged  in  favor  of  insect  transmission  is 
the  occurrence  of  the  ulcers  on  uncovered  parts  of  the 
body,  but  it  should  be  remembered  that  these  parts  are 


Fig.  28.    Leishmania  ulcer  of  the 
Oriental  Button  type.     Manaos. 

most  subject  to  traumas  of  all  sorts.  The  skin  in  the 
tropics,  owing  to  the  constant  maceration  with  sweat, 
is  not  so  perfectly  protected  by  the  horny  layer  of  epider- 
mis, and  owing  to  the  scratching  of  insect  bites,  erosions 
which  easily  become  superficial  ulcers  arise.  There  are 
mild  forms  which  closely  resemble  the  Oriental  Button 
and  which  easily  recover,  and  severe  intractable  forms. 


94 


THE  RICE  EXPEDITION  TO  BRAZIL 


The  most  intractable  forms  are  those  in  which  the 
mucous  membranes  are  attacked  and  the  disease  may 
extend  from  the  palate  to  the  pharynx  and  larynx, 
leading  to  death.  Similar  ulcers  have  been  found  in 
dogs. 

Vianna  (Arch.  hraz.  de  Med.,  Anno  II),  quoted  from 
Carini,  led  by  the  good  results  of  tartar  emetic  treat- 
ment in  trypanosomiasis,  was  the 
first  to  try  this  remedy  here.  He 
obtained  good  results  and  it  has 
become  the  accepted  mode  of 
treatment.  This  is  administered 
intravenously  in  doses  of  5  to 
10  c.c.  of  a  1  per  cent  solution. 

Of  the  ulcers  we  saw  in  the 
hospitals  there  were  a  number 
which  corresponded  with  the  de- 
scriptions given  of  these  specific 
ulcers.  They  could  be  classed 
under  three  heads.  First,  ulcers 
which  were  usually  single,  with 
firm  elevated  oedematous  borders, 
sharp  in  outline,  the  entire  ulcer 
elevated  and  covered  with  a  firm 
adherent  crust.  The  type  of  these 
is  given  in  Figs.  28,  29,  that  of  the  second  case  being  a 
healed  ulcer  of  the  scalp.  These  cases  are  very  similar 
to  the  Oriental  Button,  which,  however,  does  not  occur 
on  the  scalp.  In  the  second  class  the  ulcers,  single  or 
multiple,  are  usually  situated  on  the  extremities,  the 
edges  are  sharp  and  irregular,  the  base  covered  with  soft 
projecting  granulations.  The  ulcers  extend  laterally, 
but  chiefly  by  the  formation  of  foci  in  the  adjoining 
tissue,  which  coalesce,  giving  rise  to  large  ulcers  with 


Fig.  29.    Cicatrix  ox  scalp 

followixg  ulcer  of  the 

TYPE  OF  Oriental 

Button 


MEDICAL  REPORT 


95 


great  irregularity  of  outline  (Fig.  30) .  The  ulcers  often 
heal  spontaneously,  leaving  thin  parchment-like  cica- 
trices. 

This  character  of  cicatrix  was  very  evident  in  that 
resulting  from  a  large  ulcer  on  the  anterior  tibia  which 


Fig.  30.     A  group  of  Leishmania  ulcers.     Manaos. 

had  been  contracted  in  an  exploration  on  the  Uaupes 
river  (Fig.  31).  The  outline  was  irregular  and  the  entire 
cicatrix  was  thin,  parchment-like,  of  a  pale  blue  grey 
color,  with  superficial  tortuous  veins.  There  was  a 
marked  tendency  to  breaking  down  of  the  cicatrix  under 
slight  traumas.  The  third  type  is  that  in  which  the 
mucous  membrane  of  the  nose  or  palate  is  involved  and 
which  may  accompany  or  follow  the  skin  forms.  In 
certain  cases  a  skin  ulcer  of  the  face  may  extend  to 


96 


THE  RICE  EXPEDITION  TO  BRAZIL 


an  adjoining  mucous  membrane,  and  in  certain  cases 
the  mucous  membrane  seems  to  be  affected  primarily. 
These  cases  seemed  to  heal  up  rapidly  under  the  anti- 
mony treatment. 

Histologically  the  ulcers  differ  in  a  marked  degree 
from  typical  cases  of  Oriental  Button,  in  the  absence 


Fig.  31.  Cicatrix  on  leg  the  result  of 
Leishmania  ulcer.  The  cicatrix  is  thin, 
parchment-like,  the  edge  irregular,  no  con- 
TRACTION EXTENDING  FROM  CICATRIX.  ThE 
UNDERLYING   TISSUE   HARD   AND   ANAEMIC. 

of  the  great  numbers  of  large  phagocytic  cells  containing 
the  Leishmania.  The  granulation  tissue  is  not  very 
vascular;  there  is  marked  thickening  of  the  walls  of  the 
vessels  by  proliferation  of  endothelial  cells  and  active 
migration  of  leucocytes.  The  general  tissue  is  oedema- 
tous,  the  oedema  extending  well  beneath  the  adjoining 


MEDICAL  REPORT  97 

epidermis,  and  foci  of  fibrin  are  found  in  it.  The  pre- 
vailing cells  are  of  the  plasma  type  and  these  are  both 
collected  in  groups  and  generally  infiltrated.  The  sur- 
face is  covered  with  pus  cells  and  a  thin  layer  of  fibrin. 
The  epidermic  edge  of  the  ulcer  proliferates  extending 
over  the  surface  and  sending  deep  prolongations  into 
the  oedematous  granulations,  but  the  cells  are  separated 
by  an  intercellular  oedema  and  become  necrotic.    The 


'^^T"''"-'--...^ 

■s  '»■: '  •• 

«    •  ■    --'^    :   '  ■•   ^"  ."■'•..•'  •  .■'■  • 

Vv  .  .                               * 

-   '        :                                /^                  •,-       >                   :.       •      .-.    ;. 

>  '.    *          '           ^         i  ■ 

■%1*y'/-      ■■  '■       '*'  '    °  :■  ,      V-  ■ 'W^c,' 

^..^^.    ^■    .     .. 

■'•im\  *"  '  ^    *  " 

■  -•  .        ■'  '  ■■' '.  .  "  ■  r  ■'   ^  ■"  *  .'■•     ■'   V  '  •.-'  :'■'  "•"  '  < 

N'^*-;   ■      ■     .       ,    .        . 

'•,  '••'■'^'<A.-^:-'--' r:.y.  '}■■/  •■,-,■■-•■' ^v^,-'. t!""^. • 

l".      '.  ^■'            _    '          -. 

VV      ;"".,;'    /:      ■    ■'    .: 

'  •  ->'  •■•<•-■■  J?'"'t- ■'.:•;•. ■-'•".  ^  ■■.;•.'•  ■-"  •  '^.-  ■    '  'v    .'.■'• :  .    -'■-'" 

•c"  i/" '.  .:  '^  "    ;  . 

■  '•'*f--W^".'-."^.V:-.''x,V. './;'•'  ."  ••:-•.•  :A-<'-Y'r--x:>' 

Fig.  32.     Low  poweh  drawing  of  section  of  LEISHMA^^A  ulcer 

SHOWING   OEDEMATOVS    TISSUE   AND    ENDOTHELIAL   PROLIFERATION. 

same  process  takes  place  in  the  sweat  glands.  There  is 
but  little  proliferation  of  the  connective  tissue  and  an 
entire  absence  of  the  dense,  newly  formed  connective 
tissue  which  covers  the  base  of  our  common  ulcus 
crunis  (Fig.  32). 

All  observers  agree  in  the  great  rarity  of  Leishmania 
in  the  ulcers.  They  are  chiefly  on  the  surface  and  more 
readily  found  in  smears  than  in  sections.  In  the  older 
ulcers,  with  marked  suppuration,  they  are  generally 
absent.  We  made  a  number  of  smears  from  the  ulcers 
in  Para  and   in   Manaos,  and  were   not   able   to   find 


98  THE  RICE  EXPEDITION  TO  BRAZIL 

organisms  in  any  of  them.  These  smears  were  stained 
after  we  returned,  and  were  overgrown  with  fungi  and 
in  bad  condition.  We  also  brought  pieces  removed  from 
a  number  of  ulcers  in  securing  which  not  much  choice 
was  possible  and  several  of  them  were  evidently  from 
ulcers  of  a  different  character,  or  of  a  chronic  type.  In 
two  cases  only,  of  recent  ulcers  in  which  the  oedema 
and  indolent  character  were  marked,  were  organisms 
found,  and  that  after  a  prolonged  search.    They  were 

both  free  and  intracellular  and 
chiefly  on  and  immediately 
beneath  the  surface.  They 
each  showed  the  character- 
istic trophonucleus  and  the 
punctiform  kineto  nucleus 
opposite.  The  accompanying 
ilhistration  is  made  from  a 
Fig.  33.  Leishmania  from  skctch  by  Profcssor  E.  E. 
SURFACE  OF  ULCER.  Tyzzcr  (Fig.  33).      We  were 

not  able  to  secure  sections  from  the  ulcer  on  the  fore- 
head which  closely  simulated  the  Oriental  Button. 

Certain  of  the  large  deep  ulcers  which  we  saw  simulate 
the  simple  tropical  ulcers  and  the  sections  corresponded 
with  the  histology  of  those  which  were  studied  by  Dr. 
Wolbach  and  which  are  probably  due  to  spirochaetae. 

On  the  whole  it  seems  to  us  evident  that  there  are  in 
this  region  ulcers  due  to  a  variety  of  causes.  Some  of 
them  correspond  to  the  type  generally  referred  to  as 
tropical  ulcer,  the  most  probable  causative  organism 
being  spirochaetae.  There  are  other  ulcers,  due  to  a 
combination  of  trauma  and  general  malnutrition  (Fig. 
34).  We  saw  two  cases  in  which  the  ulcers  were  epider- 
moid carcinomas.  Syphilis  in  all  forms  is  common  and 
some  of  the  ulcers  are  probably  due  to  this.    It  is  very 


MEDICAL  REPORT 


99 


probable  that  yaws  prevails  in  the  region,  and  some  of 
the  ulcers  may  have  been  due  to  this.  Among  the  many 
names  of  the  Leishmania  ulcers  is  that  of  "  forest 
yaws."  We  saw,  however,  no  cases  of  yaws,  at  least 
none  so  diagnosed.  We  did  not  see  the  types  of  varicose 
ulcers  which  are  so  common  here.  There  are  other 
ulcers  of  a  true  specific  character,  due  to  Leishmania 


Fig.  34.     Section  of  ulcer  of  indetekmixate  type. 
Compare  with  Fig.  30. 

and  which  have  definite  clinical  and  histological  char- 
acteristics. The  thorough  differentiation  of  all  these 
types  of  ulcers  is  not  possible  with  the  facilities  which 
the  hospitals  offer.  It  is  by  no  means  certain  that  a 
careful  study  of  the  ulcers  in  our  country,  particularly 
in  the  south,  will  not  show  the  Leishmania  form  here. 


Conclusions 

No  one  can  come  into  even  superficial  contact  with 
this  vast  region  without  having  his  imagination  stirred 


100  THE  RICE  EXPEDITION  TO  BRAZIL 

by  the  thought  of  what  the  future  may  bring  forth.^  Up 
to  the  present  it  is  a  virgin  land  on  which  man's  efforts 
have  made  no  impression,  and  he  has  not  turned  the 
natural  forces  to  his  advantage.  He  has  to  a  limited 
extent  lived  in  the  region  by  utilizing  some  of  the  pro- 
ducts which  nature  so  abundantly  provides.  Some  of 
these  are  used  directly  and  for  sustenance,  others  are 
used  indirectly  and  as  objects  of  barter.  The  most 
prominent  example  of  the  latter  is  rubber  and  there  can 
be  little  doubt  that  its  exploitation  has  been  a  terrible 
calamity  to  the  native  inhabitants  of  the  country.  How 
great  this  calamity  has  been,  in  the  destruction  and 
degradation  of  the  Indian  population,  we  have  no  accur- 
ate information,  but  all  we  are  able  to  learn  shows  that 
it  must  have  been  very  great.  Of  the  other  strictly 
forest  products  nuts  come  next  in  value,  but  owing  to 
their  bulk  and  small  value,  these  can  never  be  exploited 
to  the  same  degree. 

^  Humboldt  saw  a  glorious  vision  of  the  future  with  the  utilization  by 
commerce  of  the  incomparable  system  of  waterways.  There  is  water  com- 
munication everywhere,  throughout  the  valley,  extending  into  Bolivia, 
Peru,  Ecuador,  and  Colombia,  which  could  be  easily  made  available  for 
light  draught  steamers.  Venezuela  and  the  Argentine  could  be  reached, 
the  former  by  the  Cassiquiare  Canal  and  the  latter  by  the  construction  of 
an  eighteen-mile  canal  between  the  head  waters  of  the  Tapajos  and  the 
Paraguay  rivers.  Great  interest  in  the  region  was  excited  in  our  country 
by  the  glowing  articles  of  M.  P.  Maury,  the  eminent  oceanographer, 
in  the  National  Intelligencer,  which  were  afterwards  published  in  pam- 
phlet form,  1853.  The  exploring  expeditions  of  Herndon  and  Gibbon, 
sent  out  by  the  United  States  Government,  going  into  the  valley  from 
the  west,  the  former  descending  the  Huallaga  and  the  latter  passing 
from  Peru  into  Bolivia  and  descending  the  Madeira,  added  to  the  interest. 
Both  of  these  expeditions  were  well  organized,  well  conducted  and  pro- 
ductive of  much  information  regarding  the  physical  features,  and  the 
products  of  the  land.  The  immediate  object  was  to  obtain  concessions 
from  the  governments  for  steamboat  navigation,  but  it  is  not  improb- 
able that  the  ulterior  but  more  important  object  was  to  discover  whether 
the  country  was  a  suitable  one  for  emigration  with  the  extension  of 
slavery. 


MEDICAL  REPORT  101 

There  are  present  throughout  the  region  three  con- 
ditions which  are  most  favorable  for  growth;  heat, 
abundant  moisture,  and  a  fertile  soil ;  and  the  growth  is 
prodigal.  At  Para  there  is  a  silk  cotton  tree  in  the 
grounds  of  the  museum  five  feet  in  diameter  above  the 
buttress,  which  has  grown  to  this  size  in  nineteen 
years  from  the  seed.  At  Umarituba  there  is  a  Brazil 
nut  tree  forty  feet  high  which  was  planted  as  a  sapling 
five  years  before.  Rubber  trees  grow  readily  from  seed 
and  can  be  tapped  in  fifteen  years  and  the  two  principal 
nut  trees  begin  to  bear  in  eight  years.  A  still  more 
remarkable  example  of  rapidity  of  growth  was  seen  in 
the  forest  at  San  Isabel.  An  immense  tree  in  full  vigor 
had  fallen  at  some  recent  period  for  the  dried  leaves 
were  still  retained  on  the  branches.  The  fall  of  such  a 
tree  leaves  a  definite  hole  in  the  forest  roof  which  was 
occupied  by  its  crown,  yet  at  the  time  we  were  there  the 
roof,  by  the  extension  of  the  adjoining  trees,  had  closed 
up  again.  The  bishop  of  Santarem  told  us  that  he 
obtained  three  crops  of  grapes  yearly  from  the  vines  in 
his  garden,  and  three  crops  of  corn  also  can  be  obtained 
in  the  same  year.  When  the  forest  is  removed  and  the 
land  pastured  it  produces  an  abundant,  even  luxurious, 
fine  grass  which  is  very  nutritious ;  cattle  are  fat  and  the 
pastures  seem  to  support  a  large  number  to  the  area,  in 
one  place  we  thought  about  one  and  a  half  cows  to  the 
acre.  The  great  wealth  of  the  land  is  in  the  forest  which 
covers  it  and  up  to  the  present  this  has  not  been  touched, 
no  means  having  been  found  for  its  commercial  exploi- 
tation. Bates  in  1850  speaks  of  the  great  difficulty  he 
found  in  procuring  boards  out  of  which  to  construct 
boxes  for  his  specimens,  and  the  boxes  in  which  the 
rubber  is  packed  up  to  three  years  ago  were  made  of 


102  THE  RICE  EXPEDITION  TO  BRAZIL 

imported  pine  lumber.  The  forest  undoubtedly  will  be 
utilized  but  probably  only  through  cooperative  effort 
and  on  a  large  scale.  A  great  part  of  the  country,  the 
entire  igapo  and  varzea  region,  lies  so  low  that  the 
annual  floods  will  prevent  the  utilization  of  the  land  for 
other  than  forest  culture,  and  with  the  selection  of  the 
most  desirable  and  profitable  varieties  of  trees  the  in- 
credible rapidity  of  growth  should  ensure  a  frequent  and 
abundant  harvest.  The  food  provided  by  the  waters 
is  great  in  amount  and  excellent  in  quality  and  there 
would  seem  to  be  no  doubt  that  the  region  is  capable  of 
the  support  of  a  vast  population  and  that  through  the 
utilization  of  its  surplus  product  by  sale  and  barter  great 
wealth  should  flow  into  it. 

The  first  thing  to  be  ascertained,  however,  is  whether 
the  country  is  a  possible  or  a  desirable  place  for  man  to 
live  in.  Although  all  information  regarding  the  natural 
resources  and  agricultural  possibilities  is  lacking  in 
scientific  accuracy,  the  food  supply  seems  to  be  sure,  but 
man  needs  something  more.  There  must  be  a  possi- 
bility of  life  with  the  attainment  of  some  degree  of  that 
moral  and  mental  well-being  which  we  are  accustomed 
to  associate  with  the  idea  of  happiness.  This  would 
seem  to  involve  not  too  laborious  a  life,  opportunity  for 
the  cultivation  of  the  mind  and  aesthetic  sense,  reason- 
able freedom  from  pain  and  disease  and  a  physical  envir- 
onment which  would  not  produce  constant  discomfort. 
Scientific,  accurate  information  regarding  the  diseases 
of  the  region  is  not  obtainable.  We  have  only  the  health 
reports  which  are  published  in  the  cities  and  the  very 
meagre  information  to  be  obtained  from  travellers 
and  explorers,  and  the  most  valuable  part  of  the  latter 
relates  to  the  persons  involved.  We  have  appended  to 
the  description  of  our  visits  to  the  cities  the  statistical 


MEDICAL  REPORT  103 

information  coming  from  the  health  authorities.  These 
reports  have  seemed  to  us  from  comparison  with  health 
reports  elsewhere  and  from  what  we  have  seen  in  the 
way  of  lack  of  facilities  for  diagnosis  and  general  lack 
of  accuracy  where  disease  is  concerned,  to  be  grossly 
inaccurate.  It  is  impossible  to  ascertain  the  death  rate, 
for  the  population  is  merely  conjectured  and  it  is  not  at 
all  certain  that  all  deaths  are  reported.  There  are  cer- 
tain things  in  the  reports  which  seem  obviously  wrong, 
as  the  large  number  of  deaths  from  malaria  and  the 
almost  total  absence  of  tuberculous  meningitis  as  a  cause 
of  death.  In  1909  in  Para  there  were  1159  deaths  from 
malaria,  and  taking  the  average  mortality  of  2.89  per 
cent,  this  would  give  40,100  cases  or  one  to  every  four 
and  a  half  inhabitants,  which  would  certainly  seem  ex- 
cessive. In  one  respect  the  reports  certainly  agree  with 
what  we  have  seen,  that  is  the  small  part  which  malig- 
nant tumors  play  as  a  cause  of  death.  We  never  saw  in 
the  hospitals  or  elsewhere  a  single  case  of  cancer  of  the 
breast  or  of  the  face.  The  only  cutaneous  cancers  we 
saw  were  those  associated  with  ulcers  on  the  legs  and 
other  traumas.  Two  cases  of  sarcoma  were  seen;  no 
cases  of  Hodgkin's  disease,  and  even  the  simple  tumors 
seemed  to  be  rare.  While  many  of  the  internal  cancers 
would  be  likely  to  elude  diagnosis,  those  on  the  surface 
are  obvious.  Were  the  internal  cancers  common  but  not 
recognized,  they  would  cause  a  greater  mortality  in  the 
diseases  of  the  alimentary  canal,  which,  however,  pl^y  a 
relatively  small  part  in  the  statistics.  We  think  we  are 
justified  in  saying  that  malignant  tumors  are  rare  as 
compared  with  temperate  climates.  The  statistics  are 
moreover  lacking  in  information  relative  to  age  at  death. 
In  regard  to  the  health  of  travellers  and  explorers, 
many  who  were  not  at  all  acclimated  or  accustomed  to 


104  THE  RICE  EXPEDITION  TO  BRAZIL 

the  life  of  the  country  and  most  of  whom  did  not  make 
use  of  precautions  which  we  would  now  regard  as  essen- 
tial, lived  in  the  country  without  much  disability  from 
sickness  and  without  any  permanent  impairment  of 
health.  Humboldt  had  several  attacks  of  fever  during 
his  stay  but  lived  to  an  old  age.  Both  Spix  and  Martins 
suffered  from  fevers  and  the  early  death  of  Spix  may 
have  been  partly  due  to  the  illness  which  he  underwent 
here.  Bates  also  had  attacks  of  malaria  and  probably 
dysentery,  but  attained  old  age.  Spruce  had  the  same 
experience  and  seems  finally  to  have  died  of  chronic 
ulceration  of  the  rectum,  probably  the  result  of  dysen- 
tery. The  brother  of  Wallace  died  of  yellow  fever  in 
Para,  and  the  naturalist,  though  several  times  attacked 
with  fever  while  in  the  country,  died  but  a  few  years  ago. 
Chandless  had  fever  and  indeed  this  seems  to  have  been 
an  almost  universal  experience,  although  no  mention  of 
it  is  made  in  Mrs.  Agassiz'  account  of  the  Agassiz 
expedition.  Bismarck  does  not  seem  to  have  undergone 
any  loss  of  vigor  in  consequence  of  the  year  spent  here 
as  a  member  of  the  expedition  of  Prince  Adalbert.  Rice, 
using  modern  precautions,  on  the  Uaupes  escaped  mala- 
ria but  acquired  tropical  ulcer.  Smith  was  the  most 
fortunate.  During  a  residence  of  four  years  in  the  coun- 
try, before  prophylaxis  was  known,  he  escaped  malaria 
but  on  his  return  to  the  United  States  acquired  the 
disease  after  two  weeks'  residence  in  Ohio.  There  is  an 
interesting  circumstance  regarding  malaria  which  comes 
out  prominently  in  all  the  accounts  of  the  old  explorers. 
In  the  ascent  of  rivers  all  would  go  well  until  the  upper 
waters  and  the  rapids  were  reached.  Food  was  here  less 
abundant,  the  work  of  pushing  up  the  boats  arduous, 
the  men  were  continually  wet  from  work  in  the  water 
and  constant  rains,  and  fever  would  usually  appear, 


MEDICAL  REPORT  105 

which  is  easily  understood  if  we  assume  that  the  crew 
already  had  the  disease  in  latent  form.  It  is  not  improb- 
able that  some  of  the  severe  fevers  encountered  were 
yellow  fever  and  not  malaria. 

Catarrhal  conditions  of  the  respiratory  mucous  mem- 
branes as  evidenced  in  coughing,  hawking  and  spitting, 
seem  to  be  common,  although  severe  infections  of  the 
parts  are  rare.  On  the  steamers  it  is  not  uncommon  to 
see  a  pool  of  expectoration  beneath  the  hammock.  How 
much  this  unpleasant  feature  is  merely  a  habit  or  how 
much  due  to  conditions  induced  by  constantly  smoking 
the  irritating  tobacco  of  the  country  is  uncertain.  That 
it  is  not  seen  among  the  foreigners  is  in  favor  of  its 
being  merely  a  habit.  The  health  of  our  party  was 
good  throughout,  the  only  exception  being  a  not  severe 
case  of  aestivo-autumnal  infection  acquired  during  the 
descent  of  the  Rio  Negro  by  one  of  the  writers  who  was 
somewhat  careless  both  in  regard  to  prophylactic 
quinine  and  mosquito  net. 

The  health  of  the  crew  of  the  yacht  was  good  during 
the  entire  expedition.  They  were  on  the  whole  young 
men  of  good  physique  and,  with  the  exception  of  the 
officers,  represented  many  nationalities.  The  yacht 
with  the  crew  remained  at  Manaos  for  the  three  months 
of  the  Rio  Negro  expedition.  Shore  leave  was  freely 
granted  and  games  on  shore  were  arranged  for  them. 
The  food  was  more  than  ample  and  no  change  was  made 
from  that  to  which  they  were  accustomed.  There  were  a 
number  of  cases  of  venereal  infection  acquired  at  about 
every  port,  chiefly  of  course  at  Manaos.  There  were  no 
cases  of  malaria  or  dysentery.  There  was  one  case  of 
continued  fever  which  lasted  for  four  weeks,  part  of 
which  time  was  spent  on  shore  in  the  hospital.  The 
nature  of  this  was  not  ascertained,  but  it  seemed  from 


106  THE  RICE  EXPEDITION  TO  BRAZIL 

its  course  to  have  been  a  mild  case  of  typhoid,  although 
at  the  time  there  was  said  to  be  no  typhoid  in  the 
city. 

There  are  many  foreigners  in  the  cities,  and  so  far  as 
we  could  see  these  lead  lives  anything  but  hygienic,  and 
the  amount  of  alcohol  consumed  is  enormous.  The 
drink  habit  seems  to  be  extended  in  the  region,  involving 
practically  all  who  can  obtain  alcohol.  Of  course  noth- 
ing definite  could  be  found  out  regarding  the  effect  of 
the  climate  and  the  alcohol  on  the  duration  of  life,  but  as 
far  as  cursory  observation  and  information  given  by 
physicians  and  others  enabled  us  to  judge,  the  people 
stood  the  alcohol  just  about  as  well  as  they  would  have 
in  another  environment.  It  has  seemed  to  us  if  we 
selected  the  one  disease  of  the  region  to  which  the 
greatest  degree  of  physical  degeneration  is  due  and 
which  indirectly  furnishes  the  underlying  cause  of  many 
infections,  it  is  alcoholism.  Venereal  diseases,  partic- 
ularly^ syphilis,  are  prevalent.  It  will  be  observed  that 
they  do  not  enter  at  all  into  the  causes  of  death  in  Pard 
and  to  a  slight  extent  only  in  Manaos.  Our  statement 
regarding  this  comes  from  observation  and  from  infor- 
mation gathered. from  physicians.  We  have  never  seen 
prostitution  more  open  and  more  repulsive  than  in 
Manaos,  and  advanced  cases  of  syphilis  are  not  infre- 
quently seen.  It  would  be  very  interesting  to  get  the 
Wasserman  test  of  the  entire  city  of  Manaos.  On  the 
whole,  as  far  as  concerns  health  and  food,  there  is  no 
difficulty  about  living  in  the  country.  The  greatest 
danger  comes  from  malaria  and  with  the  ordinary 
precautions  this  can  be  avoided  as  well  here  as  in  any 
region  where  the  disease  prevails. 

Probably  the  greatest  bar  to  settlement  of  the  country 
is  not  its  diseases  but  the  insects.    In  a  locality  infested 


MEDICAL  REPORT  107 

with  piums  and  micuims  life  is  hardly  endurable,  but 
the  former  are  confined  to  river  banks  in  certain  definite 
localities  and  the  latter  to  the  pastures  and  may  be 
avoided.  They  are  absent  in  all  houses,  cultivated  lands 
and  paths  which  are  kept  free  from  grass.  The  pest  of 
ants  is  a  minor  detail  and  one  easily  guarded  against. 
There  is  one  condition  which  we  have  not  seen  men- 
tioned as  pertaining  to  tropical  life,  and  that  is  a  greater 
vulnerability  of  the  surface  of  the  body.  Small  abra- 
sions and  wounds  of  the  surface  easily  occur,  giving 
possibilities  of  infection.  It  seemed  to  us  this  was  due 
to  thinning  of  the  epidermis  by  the  maceration  of  sweat 
combined  with  frequent  bathing.  Scratching  of  insect 
bites  is  particularly  to  be  avoided.  While  scratching  an 
itching  surface  gives  a  pleasurable  sensation,  the  denial 
of  this  pleasure  will  lead  to  physical  and  probably 
moral  betterment. 

Apart  from  all  these  things  is  the  country  fit  to  live 
in  ?  In  regard  to  the  effect  of  tropical  temperature  on 
the  life  of  the  white  man  the  data  at  hand  are  not  suffi- 
cient for  us  to  know  much.  The  prevailing  temperature 
of  the  region  is  undoubtedly  high  and  remarkably  even, 
probably  about  eighty  or  slightly  above  is  the  average 
temperature  of  the  valley.  There  may  be  extremes  of 
ninety-five  and  sixty-four;  we  saw  71°  Fahr.  at  San 
Gabriel  once  at  the  end  of  a  violent  rainstorm  and 
68°  Fahr.  on  the  lower  river  after  a  storm.  It  seems 
to  have  been  shown  that  the  greatest  mental  and 
bodily  activity  of  man  coincides  not  with  an  even,  but 
an  irregular  temperature.  The  experience  at  Panama 
has  shown  that  the  white  man  can  undergo  hard  physi- 
cal labor  in  a  high  temperature  and  preserve  his  physical 
well-being,  but  the  test  has  not  been  long  enough  to 
show  what  would  be  the  effect  of  continuous  residence. 


108  THE  RICE  EXPEDITION  TO  BRAZIL 

The  writers  were  not  conscious  of  any  loss  of  energy  and 
of  general  well-being  when  in  the  country  save  that  due 
to  a  malarial  attack  in  one  of  us.  The  machinery  of  the 
body  becomes  adjusted  to  the  continuous  high  tempera- 
ture, blankets  are  comfortable  at  night,  and  a  drop  of 
temperature  to  70°  Fahr.  entails  real  discomfort.  The 
eyes  also  become  accustomed  to  the  intensity  of  light, 
which  at  first  is  disagreeable,  and  shaded  glasses  become 
unnecessary.  We  did  not  find  such  intensity  of  light  in 
the  region  as  in  the  West  Indies,  which  is  probably  due 
to  the  amount  of  moisture  in  the  atmosphere  and  the 
blanket  of  clouds.  The  most  intense  light  was  given 
when  the  sunlight  at  midday  was  reflected  from  great 
cumulus  clouds  near  the  zenith.  The  time  necessary 
for  photographic  exposures  was  not  greatly  shortened. 
Nights  are  always  cool,  giving  opportunities  for  reading 
and  refreshing  sleep.  Certainly  the  work  accomplished 
by  the  naturalists  who  lived  in  the  country  shows  no 
lack  of  mental  and  physical  vigor.  This  is,  however,  an 
unfair  comparison,  for  these  men  represented  a  highly 
selected  material  who  had  work  to  do  and  an  incitement 
to  work  which  does  not  come  from  mere  living.  Whether 
the  white  man  in  the  tropics  will  expend  force  beyond 
that  which  is  necessary  for  mere  living  is  uncertain,  and 
the  probability  is  that  he  will  strive  to  lessen  even  such 
endeavor  by  compelling  others  to  work  for  him.  It  must 
be  said  that  up  to  the  present  white  men  have  not  suc- 
ceeded in  founding  a  desirable  state  of  civilization  in  the 
country,  but  there  are  various  reasons  for  this.  In  the 
first  place  the  initial  Portuguese  stock,  although  in 
the  past  it  has  produced  hardy  and  adventurous  spirits, 
represents  an  admixture  of  many  racial  elements  some 
of  them  undesirable,  and  that  part  of  it  inhabiting 
Brazil  has  undergone  deterioration  by  a  strong  inter- 


MEDICAL  REPORT  109 

mixture  of  negro. ^  Where  we  have  found  native  Portu- 
guese both  among  the  laboring  and  the  higher  class,  they 
seemed  a  virile  people.  The  foreigners  coming  into  the 
country  have  not  the  idea  of  settling  and  using  the  land, 
but  of  temporarily  exploiting  it.  A  rather  interesting 
experiment  was  made  shortly  after  the  Civil  War  when 
a  number  of  Americans  from  the  southern  states  were 
induced  to  settle  in  the  country.  The  experiment  was 
naturally  a  failure;  the  colonists  were  totally  ignorant  of 
the  country  and  were  from  a  class  which  had  always 
been  able  to  live  from  the  work  of  others.  Some  of  them 
returned,  some  died,  and  a  few  intermingled,  as  is  shown 
by  an  occasional  name  remaining.  The  captain  of  an 
English  steamer  expressed  his  surprise  to  me  at  finding 
some  Portuguese  on  the  river  named  Jennings.  Even 
the  English  in  the  tropics  have  not  been  a  working 
people,  but  have  lived  from  the  work  of  others,  though 
they  have  often  directed  the  work  of  the  natives  in 
directions  to  their  advantage.  Under  this  white  control 
in  the  English  colonies  the  natives  have  had  just  treat- 
ment and  have  attained  a  greater  degree  of  well-being 
than  without  it. 

In  this  country  there  can  be  no  possibility  of  the  de- 
velopment of  such  a  civilization  as  in  India  for  instance. 
There  is  no  population  to  furnish  labor.  The  Indians 
are  few  and  seem  to  be  rapidly  diminishing.  It  is  doubtful 

^  The  history  of  the  relation  between  the  Portuguese  and  the  Indian 
population  does  not  form  pleasant  reading.  From  the  first  their  efforts 
have  been  directed  to  the  enslavement  of  the  Indians  and  the  forced  utiliza- 
tion of  their  labor.  This  was  interfered  with  by  the  missionaries  and  led  to 
the  expulsion  of  the  religious  orders,  which  was  most  unfortunate.  The 
Spanish  civilization  entering  from  the  west  was  not  so  sordid  for  it  was 
primarily  directed  toward  the  Christianizing  of  the  natives,  and  in  the  pro- 
cess their  well-being  was  not  neglected.  The  missionary  work  of  the  Jesuit 
and  Franciscan  orders  in  South  America  forms  a  bright  page  in  the  history 
of  the  church. 


110  THE  RICE  EXPEDITION  TO  BRAZIL 

if  even  under  just  treatment  they  would  be  efficient 
in  labor,  although  the  experiment  has  not  been  tried. 
Where  a  minimum  of  work  produces  sustenance  it  is 
difficult  to  procure  labor  even  for  the  rewards  which 
civilization  offers  the  savage,  such  as  the  rum,  sewing 
machines,  music  boxes,  and  patent  medicines  already 
referred  to.  The  importation  of  Asiatics  has  been 
thought  of  by  the  government  as  a  possible  source  of 
labor,  but  it  is  doubtful  if  they  could  be  induced  to  come 
for  terms  of  years  and  the  people  fear  the  unrestricted 
competition  of  a  vigorous  race.  Whatever  the  future 
development  of  the  country,  it  seems  to  us  that  it  must 
be  by  a  people  who  themselves  will  work  and  who  will 
slowly  evolve  a  civilization  adapted  to  the  environment 
and  which  may  be  a  high  type. 

But  what  is  most  needed  in  the  country  at  present  is 
accurate  information  about  everything.  For  one  thing 
the  establishment  of  plantations  for  the  experimental 
study  of  the  agricultural  possibilities  similar  to  the  ex- 
perimental farms  which  in  all  civilized  lands  have 
proved  to  be  of  great  service.  Forestry  stations  where 
the  forest  could  be  intensively  studied  and  the  possibil- 
ities of  its  utilization  determined  would  be  of  equal  value. 
There  are  already  at  hand  admirable  opportunities  for 
the  study  of  the  diseases  of  the  country  in  such  cities  as 
Para,  where  there  is  a  well  equipped,  well  conducted 
hospital,  but  owing  to  lack  of  properly  trained  men  its 
superb  opportunities  for  study  are  not  availed  of.  It 
would  be  of  great  advantage  to  have  some  of  our  trained 
medical  students  serve  an  internship  in  this  hospital 
and  receive  the  stimulation  which  the  study  of  new  con- 
ditions brings.  Throughout  the  most  interesting  parts 
of  the  region  suitable  opportunities  for  study  do  not 
exist  and  it  would  be  important  to  establish  a  small 


MEDICAL  REPORT  111 

hospital  and  clinic  at  San  Isabel  on  the  Rio  Negro,  for 
the  intensive  study  of  the  diseases  of  this  region.    Little 
can  be  effected  by  mere  expeditions  into  the  country, 
with  superficial  study  of  conditions,  although  by  con- 
centration   on    single    problems    something    might    be 
gained.     The  physical  features  of  a  country  can  be 
studied  in  that  way  and  accurate  information  of  great 
value  obtained  as  is  shown  by  Chandless'  study  of  the 
Purus  River  and  Rice's  study  of  the  Uaupes.     The 
Agassiz  expedition  also  should  have  given  much  knowl- 
edge of  the  fishes  of  the  region  but  the  material  obtained 
was  never  described.     There  seems  in  the  hurry   of 
modern  life  and  the  intense  differentiation  of  pursuits 
no  room  for  the  man  who  was  formerly  known  as  the 
naturalist,  the  last  of  whom  seems  to  have  been  Fabre. 
We  owe  most  knowledge  of  the  country  to  such  men  in 
the  past,  who,  living  here  for  a  long  time,  have  studied 
life  in  its  environmental  relations  and  have  given  the 
world  in  fascinating  description  the  knowledge  they 
acquired.    We  allude  particularly  to  Spix  and  Martins, 
Bates,  Spruce,  Wallace,  Smith,  and  Belt,  although  the 
latter  worked  in  another  field  but  one  in  which  much 
the  same  conditions  prevailed.    All  of  these  men  had  the 
general  knowledge  which  enabled  them  to  study  bio- 
logical phenomena  in  their  mutual  relations,  and  this 
in  no  way  interfered  with  their  intensive  study  of  partic- 
ular problems.     It  is  just  this  long  continued  study 
which  is  necessary  for  acquiring  the  knowledge  of  the 
phenomena  of  disease  in  the  country,  and  which  will 
lead  to  the  solution  of  some  of  its  problems.     It  is  a 
fascinating  field  for  human  endeavor  and  should  at- 
tract to  it  men  who  are  desirous  of  a  service  which 
has  the  double  advantage  of  benefiting  mankind  and 
giving  the  worker  joy  in  his  work.    Life  in  the  country 


112  THE  RICE  EXPEDITION  TO  BRAZIL 

is  easy,  it  is  inexpensive,  the  people  so  far  as  we  have 
seen  them  are  kindly,  and  hospitality  is  shown  in  all 
directions.  It  would  hardly  be  too  much  to  say  that  a 
decent  man  provided  with  a  hammock  to  sleep  in  and  a 
few  changes  of  clothing  could  live  and  work  in  the  coun- 
try at  a  minimum  of  expense.  Medical  men  would  have 
a  great  advantage  over  other  investigators  in  that  their 
medical  knowledge  could  be  availed  of,  but  they  must 
know  how  to  pull  teeth.  There  is  one  thing  to  be  borne  in 
mind ;  the  Amazonas  is  a  country  of  one  language ;  that 
language  is  Portuguese,  and  its  attainment  is  not  easy. 
The  only  interpreters  available  are  the  Barbados 
negroes,  their  capacity  is  limited,  and  facility  in  the 
language  is  a  sine  qua  non. 

The  land  is  a  fascinating  one.  The  sky,  the  forest,  the 
rivers,  have  a  beauty  all  of  their  own  and  unmatched. 
The  great  billows  of  white  and  purple  cumulus  clouds 
rolling  to  the  west,  mounting  to  the  zenith,  changing, 
disappearing,  and  forming,  sunsets  when  sky,  air,  and 
water  all  glow  with  rosy  light,  the  still  nights  with  bril- 
liant stars  in  the  black  sky,  the  dawnless  day  when  the 
sun  bounds  into  the  sky,  the  marvellous  beauty  of  tree 
life,  particularly  the  palms,  the  great  forest,  beautiful, 
mysterious,  fear  inspiring,  unchanged  and  unchanging, 
the  exuberance  of  life,  all  these  when  once  felt  will  never 
be  forgotten. 


MEDICAL  REPORT 


113 


Barbados 

We  arrived  in  Barbados  November  23,  and  spent  two 
days  on  the  island.  It  is  a  small  (166.3  square  miles) 
very  fertile  island  of  coral  formation,  the  principal  city 
and  harbor  at  Bridgetown  on  the  west  side.    At  the  time 


] 

w 

4 

k^^^i 

if    1 

r=* 

m 

Fig.  35. 


Bridgetown:  Avenue  of 
royal  palms. 


we  were  there  the  island  was  very  green  and  beautiful 
with  great  fields  of  sugar  cane  which  was  not  yet  being 
harvested.  There  are  excellent  hotels  on  the  ocean  and 
the  climate  though  warm  is  not  uncomfortable.  Bridge- 
town is  one  of  the  most  attractive  tropical  cities  we  have 
seen,  the  streets  are  clean,  well  shaded  and  most  of  the 
better  class  of  houses  have  pleasant  gardens  with  fine 


114  THE  RICE  EXPEDITION  TO  BRAZIL 

flowers,  the  most  prominent  of  these  being  the  scarlet 
hibiscus,  and  blooming  vines  covered  walls  and  arbors. 
The  main  shade  trees  are  banyans,  mahogany  trees  and 
mangoes,  and  there  is  one  avenue  lined  with  superb 
royal  palms  (Fig.  35).  There  is  a  small  and  on  the  out- 
side attractive  looking  hospital  which  we  did  not  have 
time  to  visit.  The  main  industry  of  the  island  is  sugar, 
and  at  the  present  time  this  is  very  profitable. 

The  most  striking  feature  of  the  island  is  the  number 
of  negroes.  They  literally  swarm  in  the  town,  the  water 
side  is  lined  with  them,  they  appear  in  great  numbers 
around  the  yacht  in  rude  boats  made  of  planks  nailed 
together  and  find  both  profit  and  pleasure  in  diving  for 
coins,  showing  great  skill  in  this.  As  seen  they  are  a 
ragged,  rather  jollj^-looking  lot  and  their  nutrition  is 
good.  Fish  are  abundant  and  good,  and  with  fruit  of 
many  sorts,  and  yams  and  sweet  potatoes  and  beans, 
form  the  staple  food.  Notwithstanding  the  number  of 
negroes  on  the  island  there  is  a  large  emigration,  and  in 
Brazil  we  met  them  everywhere,  and  they  often  gave 
good  service  as  interpreters. 

The  highest  population  seems  to  have  been  reached  in 
1891  when  it  was  182,306.  In  1911  the  population  was 
171,983,  formed  by  whites  12,063,  mixed  41,533,  and 
118,387  colored.  The  birth  rate  is  high,  40  per  1000, 
the  death  rate  low,  and  the  population  is  kept  within 
reasonable  bounds  (in  1911  it  was  1034  per  square  mile) 
by  emigration.  BetAveen  1861  and  1871,  31,787  left  the 
island  and  this  rate  of  about  3000  per  year  has  kept  up; 
20,507  went  to  the  Panama  Canal  alone.  Of  course 
emigration  takes  away  the  best  part  of  a  population  and 
it  is  remarkable  that  the  present  population  should  give 
no  evidence  of  decline  in  vigor.  The  very  excellent 
police  force  on  the  island  is  negro  with  white  ofiicers. 


MEDICAL  REPORT  115 

The  relation  with  the  whites  is  good,  there  are  sufficient 
schools  and  as  we  have  seen  these  Barbados  negroes  in 
Brazil  and  in  the  United  States,  they  appear  far  more 
industrious  and  intelligent  than  do  the  negroes  of  the 
southern  states. 

The  island  must  be  regarded  as  one  of  the  most 
healthy  of  places  in  the  tropics,  so  far  as  we  have  means 
of  judging.  Law  ("  Malarial  and  Filarial  Diseases  in 
Barbados,"  Jour,  of  Tropical  Medicine,  1901)  found 
no  malaria  and  no  anopheles  mosquitoes.  Careful 
examination  of  the  water  of  the  two  swamps  on  the 
island  showed  no  anopheles  larvae  which  substantiates 
the  claims  of  Barbados  medical  authorities  that  all 
cases  of  malaria  are  imported.  Filariasis  on  the  con- 
trary is  common;  12.66  per  cent  of  600  people  examined 
showed  the  parasites  and  the  culex  fatigans,  one  of  the 
carriers  of  the  disease,  is  numerous.  A  rather  large 
percentage  of  the  positive  cases  of  filaria,  35  per  cent, 
showed  pathological  conditions,  elephantiasis,  chyluria, 
lymphangeitis,  depending  upon  this.  Daniels  also 
states  that  among  the  large  numbers  of  Barbados 
negroes  who  annually  emigrate  to  British  Guiana  he 
found  no  large  spleens  or  evidences  of  chronic  malaria. 

Porto  Rico 

On  our  return  we  reached  Porto  Rico  on  April  15  and 
spent  three  days  on  the  island.  The  harbor  of  San  Juan 
is  spacious  and  almost  landlocked,  being  inside  of  a  long 
projecting  point  on  the  north  side  of  the  island.  The 
town  has  nothing  of  the  aspects  of  a  tropical  town,  and 
is  lacking  in  picturesqueness.  The  houses  generally  of 
two  or  three  stories,  are  in  contact,  there  are  no  gardens 
about  them,  no  vines  clambering  over  walls.  The 
streets  generally  clean,  are  narrow,  as  are  the  sidewalks. 


116  THE  RICE  EXPEDITION  TO  BRAZIL 

There  are  few  trees  in  the  city,  the  pubHc  squares  are 
few  and  not  in  good  condition,  and  there  is  no  park 
worthy  of  the  name.  The  town  gives  the  impression  of 
prosperity.  The  idle  negroes  on  the  water  front,  usually 
a  familiar  sight  in  the  tropical  American  cities,  are  lack- 
ing, and  there  are  few  only  who  pick  up  a  precarious 
livelihood  as  watermen.  There  are  few  cafes  and 
drinking  houses  and  few  idlers. 

The  suburbs,  which  have  undergone  a  considerable 
extension  since  the  American  occupation,  cover  a  much 
greater  area  than  the  city  itself,  extending  for  miles  into 
the  country.  Most  of  the  houses  are  new,  a  few  of  them 
attractive  looking,  and  have  small  gardens  around  them. 
It  is  singular  that  in  building  advantage  should  not  have 
been  taken  of  what  the  experience  of  ages  has  shown  to 
be  the  most  suitable  for  the  tropics.  A  low  house  with 
walls  of  some  heat-resisting  material,  an  inner  shaded 
court,  large  rooms  with  comparatively  small  windows 
so  that  both  light  and  heat  can  be  excluded,  and  floors 
of  tile,  brick,  or  clay.  The  color  is  also  important  and 
should  not  strongly  reflect  the  sun's  rays  and  should  har- 
monize well  with  an  environment  in  which  the  verdure 
of  growing  things  predominates ;  a  soft  pink  seems  best 
to  meet  this  requirement.  The  majority  of  these  new 
suburban  houses  are  just  such  as  we  might  see  in  an 
American  suburb.  There  are  several  conveniently 
placed  and  well  operated  tramway  lines,  and  excellent 
and  relatively  cheap  automobile  lines  running  between 
all  of  the  principal  cities. 

Ponce,  on  the  south  side  of  the  island,  connected  with 
San  Juan  by  a  wonderful  automobile  road,  is  much  more 
attractive.  There  are  a  number  of  handsome  squares 
with  well  cared  for  trees  and  shrubs  and  the  streets  are 
shaded  with  fine  mango  trees.    The  houses  are  separated 


MEDICAL  REPORT  117 

and  there  are  gardens  about  them.  It  would  seem  to 
have  been  more  of  a  residence  city  than  San  Juan  and 
to  have  had  well-to-do  residents. 

The  island  is  mountainous.  There  is  an  irregular 
chain  of  mountains  in  the  centre  with  summits  up  to 
forty-six  hundred  feet  high  with  lower  mountains  which 
extend  chiefly  on  the  north  side.  On  the  south  side  the 
slope  to  the  sea  is  more  regular.  The  interior  is  much 
broken  up,  there  are  numerous  valleys,  never  broad  but 
narrow,  some  of  them  rather  ravines  than  valleys.  Nor 
are  there  any  broad  plateaus  on  the  summits,  but  the 
whole  landscape  is  broken  up  with  ridges  and  sharp 
peaks.  The  soil  appears  to  be  very  light  but  good,  and 
is  cultivated  on  mountain-sides  so  steep  that  horse  labor 
would  be  impossible. 

The  rainfall  is  abundant,  but  with  marked  local  varia- 
tions and  greater  on  the  north  than  on  the  south  side  of 
the  island.  The  soil,  notwithstanding  its  lightness, 
seems  to  possess  some  peculiar  quality  which  prevents 
it  from  washing.  Numerous  streams  come  down  from 
the  mountains  and  the  water  is  extensively  used  for  irri- 
gation on  the  sugar  plantations  on  the  south  side  of  the 
island,  this  being  assisted  by  the  construction  of  reser- 
voirs in  which  the  water  is  impounded.  There  is  inten- 
sive cultivation  of  the  land  in  the  western  two-thirds  of 
the  island,  the  main  crops  being  tobacco,  sugar,  and 
coffee.  Most  of  the  tobacco  is  grown  in  the  narrow  val- 
leys in  the  interior  of  the  island,  and  on  the  steep  moun- 
tain sides.  In  places  there  are  large  areas  of  tobacco 
grown  under  cheese  cloth.  There  are  great  plantations 
of  sugar,  generally  owned  by  companies,  and  the  culti- 
vation is  on  a  large  scale.  Coffee,  and  there  is  no  better 
coffee,  is  grown  on  the  summits  of  the  mountains  in  the 
interior.     The  coffee  plantations  received  great  injury 


118  THE  RICE  EXPEDITION  TO  BRAZIL 

from  a  hurricane  in  1898  and  have  never  recovered  from 
the  damage,  as  both  the  coffee  shrubs  and  the  trees 
which  protect  them  were  destroyed.  A  railroad,  with 
infrequent  passenger  service,  extends  around  the  island, 
with  branches  running  inland  and  from  this  there  are 
spurs  and  often  temporary  tracks  extending  into  the 
sugar  estates.  A  great  deal  of  the  cane  is  hauled  to  the 
mills  on  these  roads,  but  the  bulk  of  it  is  hauled  on  carts 
drawn  by  single  or  several  yokes  of  splendid  oxen.  The 
mills  are  large  and  placed  at  intervals.  The  population 
is  large  and  concentrated  at  more  highly  cultivated 
regions.  There  are  comparatively  few  negroes  and  the 
admixture  with  negro  blood  is  not  so  manifest  as  in 
Brazil.  There  is  a  great  concentration  of  people  in  vil- 
lages and  small  towns,  particularly  on  the  southern  side 
of  the  island,  where  the  sugar  estates  are  situated.  The 
people  of  wealth  seem  to  live  in  the  cities,  at  least  no 
large  residences  were  seen  in  the  country.  The  people, 
as  they  are  seen  along  the  roads,  and  elsewhere,  partic- 
ularly among  the  mountains,  do  not  give  the  impres- 
sion of  good  health  and  nutrition.  They  are  rather  pale, 
spare,  and  seem  devoid  of  vigor.  There  is  a  singular 
difference  as  compared  with  the  peasant  class  in  Brazil. 
Shoes  are  very  generally  worn,  although  we  did  see  an 
occasional  barefoot  laborer. 

We  had  the  opportunity  of  seeing  the  pupils  in  a  large 
public  school  of  the  middle  grade  in  San  Juan,  and  here 
the  children  in  point  of  health  and  nutrition  seemed  to 
be  in  a  fair  state.  A  primary  school  was  also  seen  in  one 
of  the  interior  towns,  and  here  also  the  much  younger 
children  looked  pretty  well.  Shoes  and  stockings  were 
generally  worn  by  the  school  children.  The  general  use 
of  foot  covering  was  probably  a  result  of  the  vigorous 


MEDICAL  REPORT  119 

hookworm  campaign  which  began  with  the  remarkable 
work  of  Ashford  and  King  in  1902. 

The  general  conditions  of  life  of  the  peon,  or  laboring 
population,  on  whom  the  prosperity  of  the  island  imme- 
diately depends,  seem  to  us  deplorable.  It  is  probably 
due  to  the  fact  that  they  own  nothing  of  the  island. 
Their  dwellings  are  the  most  wretched  shacks,  worse 
than  any  human  habitations  we  have  seen.  When 
situated  in  the  fields  the  land  is  cultivated  right  up  to 
the  houses,  giving  no  possibility  for  the  domestic  garden. 
These  shacks  are  usually  along  the  roads,  and  in  the 
vicinity  of  the  towns  on  the  southern  side  there  are  col- 
lections of  box-like  houses  so  tiny  that  it  did  not  seem 
possible  that  human  beings  could  live  in  them,  closely 
clustered,  with  no  cultivated  land  belonging  to  them. 
Fruit  is  one  of  the  necessities  of  the  tropics  and  it  forms 
in  its  many  varieties  of  bananas,  mangoes,  oranges,  bread- 
fruit, etc.,  probably  the  most  valuable  and  cheapest 
form  of  food.  In  the  rapidity  with  which  growth  takes 
place  it  is  possible  on  an  area  of  one  hundred  and  fifty 
feet  square  for  an  average  family  of  five  to  raise  all  or 
nearly  all  the  fruit  and  vegetables,  the  most  important 
of  the  latter  being  yams  and  beans,  that  it  requires.  In 
no  place  we  have  ever  seen,  save  in  the  heart  of  a  great 
city,  is  there  such  a  complete  deprivation  of  the  toiler 
from  the  use  of  the  earth  as  here.  The  wretched  peon 
must  buy  everything  and  the  very  insufficient  wage 
gives  him  only  the  poorest  food  in  insufficient  quantity. 
Meat  he  never  tastes  and  the  diet  is  practically  confined 
to  salt  fish  and  rice.  With  the  garden  it  would  be  pos- 
sible, even  without  some  use  of  the  surrounding  crops 
belonging  to  the  soulless  corporation,  though  this  might 
be  considered  legitimate,  for  the  laborer  to  raise  a  few 


120  THE  RICE  EXPEDITION  TO  BRAZIL 

pigs  and  chickens  which  would  give  him  the  requisite 
animal  food.  It  is  interesting  in  this  respect  to  recall 
conversations  which  we  had  in  Brazil  with  other  than 
the  laboring  class,  in  which  the  misfortune  of  the 
country  in  the  lack  of  an  active  and  efficient  labor-, 
ing  class  was  attributed  to  the  easy  culture  of  the 
bananas  and  the  abundance  of  fish  in  the  rivers. 
For,  said  they,  no  man  will  work  if  he  can  without 
trouble  build  a  house  anywhere  in  a  few  hours,  pluck 
bananas  at  his  doorway  and  in  a  half -hour  of  the  pleas- 
ant diversion  of  fishing  secure  the  riieat  for  a  couple  of 
days.  While  there  is  no  doubt  that  a  greater  necessity 
for  struggle  of  maintenance  will  produce  qualities  excel- 
lent for  a  race,  there  is  equally  no  doubt  that  such  with- 
drawal of  the  use  of  the  land  from  the  people  leads 
practically  to  a  condition  of  slavery  where  people  must 
work,  and  in  prescribed  ways,  in  order  to  live.  We  have 
spoken  of  this  matter,  having  in  view  not  so  much  the 
social  aspects  as  the  medical  aspects.  Medicine  aims 
primarily  at  the  freeing  of  a  people  from  the  chains  that 
disease  lays  upon  them,  disease  not  only  giving  pain  and 
.suffering,  but  preventing  the  legitimate  enjoyment  of 
the  fruits  of  life.  The  strictly  medical  work  which  has 
been  accomplished  in  Porto  Rico  by  the  campaign 
against  the  menace  of  the  hookworm,  the  provision  of 
laboratories  and  hospitals,  has  been  most  excellent  and 
beneficent,  but  restoration  of  the  use  of  the  earth  to  the 
people  in  some  measure  would  be  of  greater  value.  No 
permanent  reform,  either  social  or  medical,  will  be 
possible  without  it. 

There  is  an  interesting  relation  between  the  agricul- 
tural conditions  on  the  island  and  diseases.  Following 
the  American  occupation  there  was  a  careful  survey  of 
health  conditions  and  as  a  result  of  the  extensive  and 


MEDICAL  REPORT  121 

serious  conditions  which  were  shown  to  be  produced  Ijy 
hookworm  infestation  an  energetic  campaign  against 
this  was  instituted  in  1902  and  splendidly  directed  by 
Ashford  and  King.  Dispensaries  were  established  for 
treatment  in  the  cities  and  in  the  towns  throughout  the 
most  populous  part  of  the  island,  and  the  treatment  was 
effective,  as  shown  by  a  re-survey  and  determination  of 
hemoglobin.  It  seems  to  us,  however,  doubtful  whether 
there  can  be  a  thorough  extirpation  of  the  hookworm  in 
a  region  where  infestation  is  so  general.  The  most 
effective  measures  are  educational  and  social,  rather 
than  medicinal.  That  the  people  are  aware  of  the  na- 
ture and  importance  of  some  of  these  preventive  meas- 
ures is  shown  by  the  general  adoption  of  foot  covering. 
The  most  important  preventive  measure,  the  provision 
of  privies  and  the  prevention  of  soil  pollution  with  the 
faeces  containing  eggs,  has  made  no  headway.  It  is 
doubtful  if  there  is  a  single  privy  in  the  rural  districts  of 
the  island,  certainly  none  were  seen.  The  hookworm 
campaign,  however,  hardly  affected  the  mountain  dis- 
tricts, where  coffee  is  the  main  crop  and  where  the 
population  is  sparse.  Coffee  culture  has  not  been  pro- 
fitable, the  plantations  were  destroyed  in  1898  and  the 
coffee,  although  of  excellent  quality,  is  not  generally 
highly  esteemed  by  us  and  formerly  was  consumed  in 
Europe  exclusively.  The  coffee  of  Vienna,  which  all 
who  have  been  there  will  remember  with  pleasure,  was 
produced  in  Porto  Rico.  In  this  coffee  region  the  road 
system  which  is  so  admirable  elsewhere,  hardl}'  pene- 
trates, the  villages  are  inaccessible  and  the  bodily 
strength  and  intelligence  of  the  people  below  the  aver- 
age which  obtains  elsewhere.  The  best  of  the  population 
go  into  the  sugar  and  tobacco  regions  where  the  con- 
ditions of  life  are  more  favorable  and  the  remaining 


122  THE  RICE  EXPEDITION  TO  BRAZIL 

population  ekes  out  a  miserable  existence.  Payment 
for  work  on  the  plantations  depends  upon  the  amount 
of  labor  given  and  is  by  piece,  and  a  vicious  circle  results 
in  that  the  greater  the  weakness  produced  by  the  disease 
the  less  work  can  be  accomplished,  the  wage  is  reduced 
and  poverty  and  ignorance  are  the  most  important 
accelerators  of  the  hookworm  morbidity.  In  the  coffee 
region  there  is  universal  soil  pollution,  combined  with 
dampness  and  shade,  which  prevents  the  drying-up  of 
the  faeces;  and  the  beneficent  though  in  some  respects 
disagreeable  scavenger,  the  ant,  does  not  play  the 
important  role  which  it  does  in  Brazil.  Poverty  prevents 
in  this  region  the  general  use  of  foot  covering  which  is  a 
very  important  means  of  prevention.  Physicians  are 
few  in  the  rural  districts  and  the  poverty  of  the  people 
would  not  enable  them  to  receive  the  proper  recompense 
for  medical  work.  Under  such  conditions  practically 
the  entire  medical  care  is  taken  over  by  the  drug  stores 
in  the  villages,  to  which  the  people  resort,  and  under 
these  conditions  the  patent  medicine  evil  flourishes.  It 
is  a  pity  that  the  dispensaries  which  were  instituted 
during  the  hookworm  campaign  were  given  up  from 
lack  of  means.  Instead  of  that  they  should  have  been 
extended  and  combined  with  a  system  of  small  hospitals. 
More  important  than  roads  or  even  schools  is  the  health 
of  the  people.  Schools,  of  course,  play  an  important 
role  and  there  cannot  be  much  advance  unless  the  means 
of  communication  with  the  past  as  well  as  the  present 
be  possessed,  but  the  part  which  the  school  plays  in 
increasing  the  power,  the  well-being  and  happiness  of  a 
people  is  grossly  overestimated.  Money  had  much 
better  be  used  in  promoting  the  health  of  a  people  than 
in  an  extension  of  what  may  in  great  part  be  regarded 
as  useless  work.     A  hospital,  in  addition  to  the  imme- 


MEDICAL  REPORT  123 

diate  good  which  it  accompHshes  in  the  reUef  or  cure  of 
disease,  is  an  educational  factor  of  great  value.  And  the 
knowledge  of  proper  living  and  of  the  means  for  care  and 
prevention  of  disease  which  the  people  acquire  while 
living  in  the  hospital  is  a  part  of  education,  and  as  an 
agent  for  the  extension  of  morality  the  hospital  is  of  as 
great  value  as  a  church. 

Malaria,  of  course,  exists,  but  it  does  not  seem  to  play 
as  great  a  role  in  the  country  as  it  does  in  parts  of  the 
Amazons.  In  San  Juan  we  visited  the  small  but  excel- 
lently administered  public  hospital.  It  presented  the 
evidence  of  what  excellent  work  can  be  accomplished 
with  means  seemingly  inadequate  but  used  with  intel- 
ligence and  directed  by  scientific  enthusiasm.  The 
hospital  is  an  old  building,  small  and  inadequate.  It 
did  not,  for  instance,  compare  in  material  aspects  with 
the  hospital  in  Para,  but  one  had  only  to  enter  the  wards 
to  see  that  a  totally  different  spirit  prevailed.  The 
manifest  difference  was  accuracy  of  diagnosis,  knowl- 
edge of  the  condition  of  the  patients,  based  on  scientific 
study,  and  with  this  a  far  greater  interest  in  the  patients. 
This  seemed  to  be  due  to  the  presence  in  the  hospital 
of  a  trained  pathologist  with  a  laboratory  pretty  well 
equipped  for  simple  work,  and  who  possessed  energy 
and  scientific  interest.  One  thing  we  were  told  there 
which  was  interesting,  was  the  relation  between  child- 
birth and  malaria.  In  patients  with  chronic  malaria, 
but  who  showed  no  symptoms  whatever  of  the  disease, 
childbirth  was  frequently  followed  by  an  acute  exacer- 
bation of  the  disease.  This  was  probably  to  be  attri- 
buted to  the  increased  intra-abdominal  tension  of 
labor,  forcing  into  the  circulation  organisms  Avhich  were 
quiescent  in  the  spleen.  By  work  in  the  hospital  the 
great  frequency  of  filaria  in  the  island  was  determined. 


124  THE  RICE  EXPEDITION  TO  BRAZIL 

This,  however,  seems  to  produce  no  symptoms.  We 
were  informed  by  the  very  capable  administrator  of  the 
hospital  that,  owing  to  the  increased  cost  of  living,  his 
salary  had  been  reduced. 

We  also  had  the  pleasure  of  visiting  the  government 
laboratory,  which  is  under  the  direction  of  Major  Ash- 
ford.  It  is  a  well  provided  and  administered  institution 
and  was  organized  shortly  after  the  American  posses- 
sion. The  laboratory  was  the  efficient  instrument  in 
the  suppression  of  yellow  fever  on  the  island,  the  centre 
from  which  the  hookworm  work  extended,  and  from  it 
have  come  some  notable  contributions  to  knowledge  of 
disease.  The  most  recent  of  these  has  been  the  work 
showing  the  etiology  of  sprue,  which  is  one  of  the  serious 
tropical  diseases.  What  a  change  is  represented  in  the 
general  point  of  view  when  almost  the  first  thing  which 
a  government  does  when  it  becomes  possessed  of  a  new 
land  is  to  establish  a  laboratory  for  the  investigation  of 
disease !  On  the  medical  care  of  the  people  and  the  pre- 
vention of  disease  the  happiness  and  well-being  of  the 
people,  and  the  success  of  the  administration  primarily 
depend. 

The  schools  on  the  island,  each  proudly  displaying  an 
American  flag,  are  numerous,  and  those  we  visited  were 
well  attended  and  administered.  Of  those  in  the  coun- 
try districts  we  could  not  judge.  We  were  informed, 
however,  by  the  principal  of  one  of  the  high  schools  that 
the  accommodations  were  inadequate  and  that  two  hun- 
dred and  fifty  thousand  children  on  the  island  were 
without  schools,  but  this  is  probably  an  exaggeration. 

It  is  impossible  to  leave  this  very  interesting  island 
without  offering,  but  in  a  spirit  of  modesty,  certain  sug- 
gestions. All  suggestions  of  course  should  be  made  with 
a  full  knowledge  of  environmental  conditions,  and  these 


MEDICAL  REPORT  125 

cannot  be  ascertained  in  a  visit  of  three  days  only.  Cer- 
tain things  seem  to  be  apparent,  but  whether  the  sug- 
gestions could  be  put  in  force  and  whether  if  so  they 
would  be  beneficial  must  be  left  to  the  judgment  of 
others.  The  first  would  be  in  regard  to  the  relations  of 
the  laboring  class  to  the  land.  The  people  should  live 
on  the  land  where  they  find  employment  and  each  house 
should  be  provided  with  land  on  which  the  settler  could 
raise  an  important  part  of  his  food.  Provision  should  be 
made  by  the  government  for  the  people  to  acquire  pos- 
session of  a  home  on  easy  terms.  The  collections  of  dog 
houses  about  some  of  the  towns,  in  which  the  people 
live,  should  be  destroyed.  It  is  such  conditions  in  which 
the  people  have  no  stake  in  the  land,  nothing  to  lose, 
and  possibly  something  to  gain,  by  a  change,  which 
make  revolutions  possible  and  true  progress  impossible. 
We  believe  that  this  is  in  all  respects  the  most  important 
social  and  medical  reform  which  can  be  instituted.  The 
second  suggestion  is  the  reestablishment  and  the  con- 
tinuance of  the  medical  foci  for  the  relief  of  hookworm 
disease  and  other  conditions.  The  wealth  of  the  island 
primarily  depends  upon  the  efficiency  of  the  labor  used 
in  the  cultivation  of  the  soil,  and  a  laborer  in  whom 
hemoglobin  is  deficient  can  never  be  efficient. 

Such  a  small  island  as  this  presents  an  interesting 
problem  in  government.  There  is  sufficient  diversity 
of  interest  to  present  problems  of  public  economy,  and 
conditions,  both  of  population  and  region  vary  suf- 
ficiently to  produce  many  problems  of  public  health. 
The  environment  is  small  and  the  interrelations  are  not 
so  complex  as  to  render  the  problems  insoluble.  More- 
over, mistakes  both  in  political  and  health  management 
are  not  so  productive  of  harm  as  in  more  complex  rela- 
tions, the  results  are  more  quickly  manifest  and  changes 


126  THE  RICE  EXPEDITION  TO  BRAZIL 

can  be  more  quickly  made.  In  a  certain  way  an  island 
can  be  regarded  as  an  experimental  station,  where  vari- 
ous experiments  in  administration  can  easily  be  made 
and  would  entail  little  cost.  For  instance,  on  such  an 
island  the  very  interesting  question  as  to  the  possibility 
of  hookworm  extirpation  and  even  the  best  methods  of 
permanent  relief  could  be  determined.  Experiments  in 
government  might  also  be  used  to  determine  what  is  the 
end  to  be  striven  for,  the  general  well-being  and  happi- 
ness of  the  people  as  a  class  or  the  unrestricted  exploita- 
tion of  both  the  soil  and  the  people  towards  the  end  of 
wealth  production.  Living  problems  of  education  could 
also  be  tried  out  experimentally.  It  seems  to  have  been 
shown  that  a  nation  by  means  of  education  carefully 
directed  to  one  end  and  embracing  such  means  of  educa- 
tion as  the  school,  the  university,  the  press,  the  pulpit, 
and  the  army,  can  be  radically  changed,  at  least  for  a 
time.  It  might  be  determined  whether  nobler  ideals 
than  even  well-being  and  happiness  can  be  attained  or 
whether  all  effort  is  vain. 


PRINTED  AT 

TOE  OABVARD  UMVERSITT  PRBaS 

CAMDHIDGE,  MAHtt.,  C.  8.  A. 


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